Coronial Findings

Record of Investigation into Death

Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4
I, Ian Roger Matterson, Coroner, having investigated the death of

the deceased



The deceased died on the 14th August 1999.

The deceased was born in Hobart on the 27th October 1948 and was aged 50 at the date of her death. She was divorced and a disability pensioner at the time of her death.

I find that the deceased died as a consequence of chronic obstructive airways disease complicated by the effects of drugs.

At the time of the deceased’s death she was not being treated by a medical practitioner.


The deceased lived alone.

The deceased had been treated by her general practitioner, Dr. McLeod, over the 15 year period before her death for a number of problems. These included chronic pain, a personality disorder, depression, chronic airways disease, gastro intestinal tract difficulties and substance abuse. She had also been referred to the Pain Clinic at the Royal Hobart Hospital and to psychiatrists Dr. George and Dr. Lopes. The deceased had numerous hospital admissions over the years, some of which related to concerns about suicide and others which related to complaints of chronic pain and respiratory difficulties. Dr. McLeod reported that one of these admissions relating to respiratory failure was thought to have been caused by a combination of methadone and the chronic airways disease from which the deceased suffered. Dr. McLeod also reported that the deceased had on occasion asked for details about euthanasia.

In 1993 the deceased was prescribed methadone for chronic pain. Over the following years she continued with this and other medications. In 1997 when the deceased was first referred to Dr. Lopes she was still on methadone. He saw her regularly after that in 1997, 1998 and 1999. At the end of January 1999 he stopped prescribing methadone believing the deceased was taking too many drugs and he was concerned as to the effect on her health of the combination and quantity of drugs she was taking. The deceased was apparently unhappy with this and placed pressure on Dr. Lopes to prescribe methadone again. She complained to outside people that she was not receiving proper medication for her pain and it went so far that her local minister contacted Dr. Lopes to know why he would not give the deceased proper pain medication.

In March 1999 Dr. Lopes relented. He recommenced prescriptions of 2 drugs, Physeptone (methadone) and Proladone (oxycodone pectinate). At the same time the deceased was also being prescribed an antidepressant.

Dr. Lopes described the deceased as having a long history of depression and said she complained frequently of pain. At times when he saw her she was teary and vague. At times he questioned her about whether she was medicating herself correctly. At these times she denied she was misusing her drugs and said it was just the pain that was affecting her. His view was that she was well educated in the use of her medication, particularly the methadone and was capable of medicating herself. He said she understood what she was taking, why she was taking it and what the potential side effects were. He was however not aware of any occasion where she had deliberately taken more than a prescribed dosage.

Dr. Lopes last saw the deceased on the 12th August 1999, that is 2 days before she was found dead. He described her as alert and in good spirits and not apparently adversely affected by any medication.

The deceased’s daughter, Jocelyn, confirmed concerns about the effect of drugs on the deceased’s already fragile health but also that methadone levels had been adjusted to take the effect into account.

On the 12th August the deceased visited her daughter Jocelyn and remained with her until about 8.30 p.m. The deceased made contact with her second daughter by phone later on the same night. Both reported the deceased to be in good spirits. The next day Jocelyn tried to telephone her mother several times but could not raise her. She went to her unit at about 10 p.m. that night but no one answered the door and she could not see her mother through any of the windows. She reported that she was however not worried about her mother’s frame of mind and knew she had plans to meet a friend. However on Saturday the 14th when she still could not raise her mother, she and her husband went to the deceased’s unit.

They broke into the unit and found the deceased in her bed. It was apparent to ambulance officers who attended that the deceased had been dead for some time. There was no indication of anybody apart from the deceased’s daughter forcing entry to the unit and no apparent signs of any violence having occurred.

Post mortem and toxicological examinations were conducted. There were no signs of any injury or violence. The toxicological examination revealed the presence of some alcohol and a number of drugs in the deceased’s system. The alcohol, drugs and their levels were described as follows:


0.022 g/100ml




within normal range





0.03 mg/L(S)



0.06 mg/L(S)



0.2 mg/L(S)



0.5 mg/L(S)

greater than therapeutic

The toxicology report contained the following comments:

“Alcohol, diazepam and methadone are central nervous system (CNS) depressants. Trimipramine has sedative properties. In combination, the depressant effects of each drug are enhanced by the others. In a drug naïve individual, the drug combination identified may be potentially lethal.

In tolerant individuals without underlying disease or disorder the drugs identified may be incidental findings. However, the development of tolerance to each of the pharmacological effects of a drug is not uniform. Consequently, the risk of respiratory depression by methadone remains particularly when in combination with other depressants.

In a tolerant individual with, for example, a compromised respiratory system, the drugs identified may have had a contributory role in the death.”.

Health Department information relating to the drugs supplied by Dr. Lopes to the deceased indicated that his application to prescribe Physeptone and Proladone for longer than the usual periods was referred to a clinical advisory committee. Authorisation to prescribe was last approved by that committee on the 29th July 1999. In addition information was supplied about the drugs themselves. The department also supplied further information was as follows:

“Methadone is an opiod narcotic used mainly in the treatment of chronic pain conditions and in maintenance regimes for drug dependent persons. It is longer acting than Morphine and its elimination from the body can take up to 72 hours with continued use. Its analgesic effect usually lasts less than 24 hours, but longer in some patients and with accumulation during continued use. It is most suited to oral therapy for chronic pain, but must be used with an understanding of kinetics. Cumulative toxicity is usually heralded by sedation and confusion.

The approved prescribing information lists a contra-indication of “respiratory depression, especially in the presence of cyanosis, excessive bronchial secretions, obstructive airways disease”. Clinical judgement would be required as to the severity of any of the patient’s conditions and if prescribing was therefore warranted. It is not unusual for specialists to prescribe, based on full clinical circumstances, contrary to textbook recommendations.

Oxycodone is a potent synthetic opiod, with better oral bioavailability and slightly longer duration of action than oral morphine. Efficacy and adverse effects are similar to those of morphine in that respiratory depression may occur with patients naïve to the drug and those with severe respiratory depression but does not generally occur with maintenance dosing. Oxycodone is well, but slowly, absorbed through the rectal mucosa. A clinical duration of analgesia of seven (7) or more hours, makes it useful as a night time suppository.”

A quantity of a number of medications was found in the deceased’s unit. It was not possible to determine precisely what she had taken prior to her death and the toxicology results do not necessarily suggest any overdose of any particular drug. There was no suicide note and no indication to family or medical practitioners who saw the deceased within 48 hours of her death being discovered that she may have been considering suicide. It might have been expected given the deceased’s history that, had she been particularly down and considering taking her life, she might have said something to that effect.

On the balance of the evidence available to me I am satisfied the deceased did not ingest medication with the intention of taking her life. The evidence suggests that the long term use of a combination of the drugs Physeptone, Proladone and Trimipramine combined with alcohol and the deceased’s chronic airways disease produced respiratory depression leading to death.


Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This is not the first case either in Tasmania or elsewhere in Australia where this type of death has occurred. It should be a reminder to all medical practitioners of the dangers associated with prescribing combinations of powerful drugs to any patient and more particularly so to one with pre-existing health problems such as those from which the deceased suffered.

This matter is now concluded.

DATED : Friday, 4 March 2005 at Hobart in the state of Tasmania.

Ian Roger Matterson