Inquest into the death of Jay Alan Paterson

43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury

Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone tablets in August 2017 by leveraging regulatory differences between ACT and NSW, falsely reporting medications stolen or confiscated. On 30 August, Dr R. prescribed additional opioids after a phone call from Mr Paterson's wife raising concerns, without physical examination or verification of medication possession. Mr Paterson was found unconscious on 31 August with toxic levels of oxycodone and clonazepam. Intubation was technically difficult due to anatomical factors and laryngeal calcification; tracheal perforation occurred but was surgically corrected. The coroner found the intubation complications were unavoidable given anatomical findings, but identified systemic issues with cross-jurisdictional opioid prescribing as a public safety matter. No individual clinician referral to AHPRA was warranted.