Inquest into the Death of Marjorie Joy JARICK

54y · Female·Opioid toxicity (predominantly fentanyl)

54-year-old woman with diabetes, obesity, and multiple opioid allergies underwent groin surgery at a private hospital. Anaesthetist Dr Y. prescribed a 75mcg/hr fentanyl patch post-operatively for chronic pain management due to the patient's intolerance of oral opioids. The patient had been reviewed by pain specialist Dr H. who recommended methadone instead, but this consultation was not communicated to Dr Y.. The patient vomited medications on the evening of 9 July and developed reduced oxygen saturation (94%), but was re-dosed with methadone without escalation to the anaesthetist. She was found unresponsive after midnight and could not be resuscitated. Death was attributed to opioid toxicity from the combination of fentanyl patch and other opioids. Clinical lessons include: avoid fentanyl patches in perioperative settings except for chronic pain patients; ensure communication between specialists about pain management plans; implement enhanced monitoring protocols (at least 2-hourly observations) when opioids are started; escalate respiratory depression signs (low oxygen saturation plus vomiting) to senior medical staff; and restrict fentanyl patch prescribing to specialists only.