Deceased
NE CH SH
Demographics
31y, male
Coroner
Coroner Michelle Hodgson
Date of death
2012-06-10
Finding date
2012-07-06
Cause of death
mixed drug toxicity
AI-generated summary
A 31-year-old man died from mixed drug toxicity involving a lethal combination of fentanyl, ketamine, hydromorphone, morphine, codeine, paracetamol and cannabinoids. The deceased had access to powerful palliative medications prescribed to his wife who died of cancer one year prior. Despite being aware he was experimenting with these medications, family members did not prevent access or ensure return to authorities. There was no systematic process to retrieve dangerous Schedule 8 medications after the patient's death. The coroner identified a critical public health gap: no authority bears responsibility for retrieving potent controlled substances from deceased patients' homes, creating significant risk to vulnerable family members. The case highlights need for coordinated medication retrieval protocols involving GPs, police, and ambulance services.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: COR 2012 002188
Form 38 Rule 60(2) Section 67 of the Coroners Act. 2008
I, Michelle Hodgson, Coroner, having investigated the death of NI CH SH without holding an inquest:
find that the identity of the deceased wes NE Cis
born on 27 November 1980
and the death occurred on 10 June 2012
at 10 Ainley Street, BROWN HILL 3350 VIC
from: l(a) MIXED DRUG TOXICITY.
Pursuant to section 67(2) of the Coroners Act 2008 there is a public interest to be served in making findings with respect to the following circumstances:
The Coroners Court is different from other courts. It is an inquisitorial rather than an adversarial system. In other words, there is no trial, with a prosecutor and a defendant.
Instead, there is an inquiry that seeks to find the truth about a person’s death — to establish what happened, rather than who is to blame. The Coroner is more flexible in the evidence that they will accept, but they cannot punish.
When making a chambers finding, coroners carefully consider all the submissions that come before them. Not every issue makes it way into the final report but everything has been weighed up and analysed.
Mr NERS CH SHB was 31 years of age when he died of a lethal combination of fentanyl, ketamine, hydromorphone, morphine, codeine, paracetamol and cannabinoids.
Mr SSR s body was found by his sister-in-law, Mrs Mi sa at his home at 10 Ainley Street, Brown Hill.
Mrs Shad last seen her brother in law at a local play centre at around 3.00 pm on 9 June 2012.
Mr S#iJhad been expected to meet friends and family for a football game on Sunday 10 June 2012, and when he didn’t arrive, his brother telephoned his wife to check if “everything was O.K.”
Mrs SHfound Mr SHEBin his bed. Mrs SIiilwas unable to rouse him and rang her husband, a friend and emergency services.
Shortly thereafter emergency services arrived.
It would appear that Mr SI was already deceased before Mrs SMBarrived at the home.
Mr SH wife, BEBBJhad died of cancer on 2 June 2011.
BURR and Mr SHB had been married in 2007.
Together they had two children, Am and viF—Z
It was just before Christmas 2010, that BIEwas diagnosed with advanced bone cancer.
Mr S§then became her carer.
Family and friends have nothing but praise for the manner in which he handled his wife’s devastating terminal illness.
When NEE found out BEIIMB had cancer, NE was very good to P/E and his focus was on BEEEEEB and his children?
Fis attitude towards BYE dying was one of acceptance and he showed no signs of depression or anything like that Mr Si appeared to be coping with the death of his wife and the care of their two
young children.
However some friends and family subsequently expressed concerns about how well he was coping emotionally
I noted that the fantastic job he was doing with his studies and how he was with kids.
? 4 October 2009
° Statement of mother in law Ms JG V ggg
1 would say in regards to N@HEB’s mental state in the lead up to his passing that he was extremely happy and content with his life and excited about the future. He enjoyed his studies and maintaining a well run household.
However, he was beginning to display slightly manic and paranoid behaviours.”
He always put his kids before anything and was determined to be the best Dad to them and raise them after his wife died®
MEE really struggled after PEE death and was in quite a rut for a while, but he started to pick up as the year passed and was the happiest I had seen him in a while just prior to his death. He wanted to make a good life for his kids and had gone to university to study teaching’
T would say in regards to N's mental state in the lead up to his passing that he was extremely happy and content with his life and excited about the
futures
After MEBs wife BIE passed away from cancer he appeared to be going ok and was handling it?
In his relation to how NE was coping with my daughter's passing with cancer he was dealing with it better than anybody.
He was really excited about his future. The last time I saw NEE was in May for Mother’s Day. He was really happy but looked a little thin.'!
The toxicological report disclosed the presence of fentanyl, hydromorphone, ketamine, morphine, codeine, paracetamol! and cannabinoids.
° Statement of SI US
° Statement of ME
® Statement of Sig
© Statement of Wi Vi " Statement of KH
On 18 June 2012, an autopsy was performed by Doctor Matthew Lynch, a Medical Practitioner practising as a specialist in forensic medicine and pathology.
He stated that the cause of death was “mixed drug toxicity”.
Detective Senior Constable Troy Wickham of Ballarat Police located a Tupperware container in Mr SIRs bedroom.
The following packets of medication were located in that container bearing the name
of BEE Skewes:
2 x Fentanyl Citrate 400 mcg Lozenge 20 pack unopened
1 x Midazolam Sandoz 5 mg/1 ml 10 ampoules (4 missing) 1 x Ketamine 200 mg/? ml 5 vial pack ( 2 missing)
1 x Hydromorphone 10 mg/1 ml 5 ampoules (2 missing)
1 x Fentanyl 00 micrograms/hr 5 patches (4 missing)
1 x Maxolon 10 mg/2ml 30 ampoules (21 missing)
Also located was a yellow sharps container with used syringes and opened vials inside. This was located inside a brown paper bag on the top shelf of the wardrobe above the set of draws.
Two x Glad snap bags of green vegetable matter believed to be cannabis was located as well as an “inhaling” machine.!
Fentanyl is a very powerful narcoctic often prescribed for pain management in cancer patients. It has a potency 100 times of morphine.
Hydromorphine is a narcotic analgesic similar to morphine but having approximately eight times greater potency than morphine.
” Sergeant Travis Barber describes this device "This device is used for heating up substances which causes the substances to fume with the contents of the substance exiting the top of the device. The device is then fitted with a plastic bag to capture the fumes. Once the fumes have been trapped in the plastic bag, the user would then inhale the fumes form the plastic bag.”
Ketamine is an anaesthetic.
Midazolam is a drug of the benzodiazepine class.
It would appear all of the drugs had been appropriately and legitimately prescribed for the palliative care of RSH
Some family and friends were aware that Nba been using his deceased wife’s medications before his death.
A few months prior to NEE’s death, he told me that he had used some of the medication, the Morphine and the Ketamine. I think he said he had injected.
He told me that it made him feel really relaxed.”*
On the Friday night before his death, a friend, Aaron Brown was told by Mr SHE that he had been experimenting with BIEEEEEPs cancer medication.
NUH told me that he might inject some morphine that night if he gets time, but if not, then he would do it the next night.
He then went on and showed me where he stored the drugs.
Ll asked if he was meant to take this stuff back, and he said he was meant to but
decided to keep them. He said that he told his father in law, BU ME hat he had already taken it back.“4
His father-in-law, Mr MII states that he made it known to Mr SIthat he had to return BIE s medication. Mr M[states that
“the actual container with BIEEEEs medication disappeared and I never saw it again. vis
® Statement of JI SH
Statement of AM
Sean LI another friend, stated that he knew Mr SEE would smoke cannabis on what he described as a “semi-regular” basis and that he had given this up for a period of time at the request of his parents in law.
Mr LE stated that 3 to 4 weeks prior to his death, Mr Mliihad called him to at his home due to his (Mr SI) concerns about the effect that ketamine was having on him.
‘eel ccxme aware that the ketamine was medication leftover from when Mr g had been caring for BEE
Mr Lif had a discussion with Mr SHE who advised that he had no ketamine left.
Mr L§ithen raised concerns about Mr S§iwell being with Mr A
Given Mr SJ apparent functioning he determined to spend more time with him
and “see how things went.?'®
Mrs vi’ stated that she was “not sure if NEBjwas using BEBE old medication”.
Most of Mr SEE family and frionds were aware that he smoke cannabis from time to time but did not perceive it as problematic.
AMIS SQ was the older brother of NEM and he checked the internet history of NEB ss computer after his brother’s death.
This search disclosed Mr SIiilaccessing information on various sites relating to the use of hydromorphone and other opiates.
Several family members'* expressed concern that large amounts of BA's potent medication remained in Mr SIs possession subsequent to her death.
There is nothing to suggest that the overdose was deliberate.
Statement of SI
Hig mother inlaw
° Va
Mr Shad told Aug BEE that he intended to inject some morphine on either the Friday night or the Saturday night being the night of his death.”
It would appear that Mr Ssent a text message to an Aunt at 10:45 pm on 9 June
Section 67 (3) of the Coroners act 2008 states that A coroner may comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice
The issue that relates to public health and safety raised by the death of Mr SIs in relation to the retrieval of medications following the death of the person to whom they were prescribed.
Powerful medications are often prescribed for the terminally ill to manage otherwise intolerable pain.
Most medications that might be left behind after a person dies and presents a serious risk to others would be included in Schedule 4 or Schedule 8 of the Poisons Standard.”
Under the Drugs, Poisons and Controlled Substances Act 1981 (Vic), a person is authorised to possess a Schedule 4 or Schedule 8 medication only to the extent and for the purposes for which it is supplied.
Under the Drugs, Posions and Controlled Substances Act 1981 (Vic), the unauthorised possession of a Schedule 4 or Schedule 8 medication is an indictable offence. For Schedule 4 or Schedule 8 medications prescribed to a person, if that person dies nobody else if authorised to possess the medications (as the purpose of the medications was to treat the deceased person). Therefore the law requires that the medications should be returned or retrieved for destruction.
There is no authority that bears responsibility for the retrieval of such powerful and dangerous substances after the death of a person to whom they have been prescribed”!
?° Poisons in this context encompasses a broad range of substances that have the potential to harm humans and/or animals, including medications, illegal drugs, pesticides, paints and alt manner of chemicals for household and industrial use. The level of Schedule determines the level of control over the availability of that poison. Posions for therapeutic use (medicines) are mostly included in Schedule 2,3,4 and 8 with progression through these schedules signifying increasingly restrictive regulatory controls.
find that Mr NE CH SB diced of mixed drug toxicity, due to the ingestion of his deceased’s wife powerful palliative medication.
Pursuant to section 72(2) of the Coroners Act 2008, | make the following recommendation(s) connected with the death:
The Victorian Department of Health consider consulting with relevant bodies whose members have contact with the family of the deceased after a death, such as Victoria Police, Ambulance Victoria and the Royal Australian College of General Practitioners, to identify any appropriate opportunities to retrieve medications (particularly Schedule 8 opioids) that had been prescribed to the deceased thus reducing harms associated with other people accessing and using those medications.
Signature:
Michelle Hodgson
Date: be te EO 7B,
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