Inquest into the death of Robert MAXFIELD

45y · Male·multiple drug toxicity

Robert Maxfield, a 45-year-old inmate at Cooma Correctional Centre, died from multiple drug toxicity involving methadone and mirtazapine. He had a history of drug dependence and mental health conditions (schizophrenia, depression) managed with olanzapine and mirtazapine. Although not enrolled in the methadone program, he obtained methadone covertly—likely through diversion from other inmates or unauthorised sources. His mirtazapine levels exceeded prescribed amounts, suggesting overuse. The coroner found no deficiency by correctional or health services. Clinical lessons include: recognising overdose risk in inmates with substance use histories; monitoring medication compliance in custody settings; and considering alternative opioid treatments (buprenorphine injections) to reduce diversion opportunities.