Coroner expresses concern over man’s overdose death


The GP who prescribed methadone to a Tasmanian man was found to have breached the Poisons Act on 35 occasions

A 51-year-old Tasmanian man died from acute methadone toxicity in January last year, leading the state’s coroner to comment on the importance of adhering to safe prescribing regulations.

Police located a methadone blister pack at the scene containing six tablets, with four of 10 having been used and in a box that had originally contained 20 tablets. No other methadone was located at the scene.

While nothing was found to suggest that the man’s death from methadone overdose was a suicide, for example a note or farewell letter, the Coroner could not determine conclusively whether that overdose was deliberate or accidental.

An autopsy revealed evidence of methadone ingestion, with the man having 2.5 mg/L of methadone in his body at the time of his death – “a level within the reported fatal range,” said Coroner Simon Cooper.

Due to chronic ongoing pain, the man had been first prescribed methadone in about 2011 while living in Queensland. Meanwhile the first record of him receiving any medication in Tasmania was when he was prescribed morphine in March 2012.

Records indicated that he was first prescribed methadone in Tasmania in April 2012.

It became apparent from medical records obtained as part of the investigation that the man was a long-term patient of a general practitioner who prescribed methadone in tablet form for him “for a considerable period”, since at least March 2014.

This GP was found to have prescribed the methadone which was implicated in the man’s overdose death.

As part of the investigation into the man’s death, records relating to his methadone prescription were obtained from the State Chief Pharmacist.

Those records indicated that the man’s general practitioner, as identified by the Pharmaceutical Services Branch (PSB) of the Department of Health, breached the Poisons Act 1971 a total of 35 times.

The Poisons Act is the legislation which regulates the prescription and supply of methadone, among other things.

In a report to the Coroner, the Chief Pharmacist said: “…The vast majority (23 of the 35) [breaches of the Act] relate to prescription supplies by [the general practitioner] where prior authorities had expired and the prescriber had not sought further authority…

“The remaining 11 breaches are more technical in nature and risk assessed by PSB pharmacists as not clinically relevant to patient safety.”

The Coroner observed that the issue of methadone prescription has been the subject of comment by coroners in a number of cases in Tasmania.

“Nonetheless, deaths from methadone toxicity continue to occur,” he said. “So do breaches of the law by prescribers in relation to the prescription of that potent drug.

“I consider it necessary to comment that the regulatory regime established by the Poisons Act 1971 is designed to ensure the safe use of methadone.

“A failure to adhere to the requirements associated with the prescription of methadone is a serious matter with the potential to have serious and indeed fatal consequences for patients.”

However the Coroner declined to provide any recommendations or referrals on the matter.

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