Inquest into the death of Heather Fotiades

43y · Female·acute multiple drug toxicity on a background of chronic pain and morbid obesity

A 43-year-old woman died from acute multiple drug toxicity after 26 years of high-dose opioid therapy for chronic pain following a motor vehicle accident. Despite recognition by multiple clinicians that opioid doses exceeded safe levels (220-230mg OxyContin daily equivalent to 330-345mg morphine) and were ineffective for pain, doses were not reduced and were actually increased following hip replacement surgery. Key clinical failures included: lack of coordinated management plan between specialists and general practitioners; failure to detect prescription shopping when patient obtained opioids from two prescribers simultaneously; prescribing multiple opioids concurrently with sedating drugs in an obese patient with respiratory risk factors; discharge from hospital on higher opioid doses without tapering plan; and absence of addiction medicine specialist input. The coroner found this was a preventable death that should have been foreseen.