Inquest into the death of Andrew Gilbertson

42y · Male·methadone toxicity

Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but had diverted methadone in the past. He failed to attend a scheduled Drug and Alcohol appointment on 10 September 2019, one week before his death. The coroner found the death was due to misadventure—ingestion of diverted methadone without tolerance. Key clinical lessons include the risks of unmanaged opioid diversion in custodial settings and the importance of completing pre-release assessments. Justice Health subsequently implemented monthly buprenorphine depot injections as standard opioid substitution therapy in January 2020, preventing diversion and reducing fatal overdose risk.