Man prescribed ongoing narcotic pain relief by doctor despite history of alcohol and substance abuse, dies from drug toxicity.

Investigation into the death of SJM

Coroner: James McDougall
Date of Death: 8 July 2012

Issues for Consideration:

  1. Inappropriate prescribing practices.

Factual Summary:

SJM, aged 57, had a history of alcohol and substance abuse, type 2 diabetes, gout, insomnia, anxiety and depression. His general practitioner of thirteen years, Dr JB, had a history of treating SJM for these conditions using a combination of prescription medication, including narcotics. Dr JB had a documented history of concerns regarding SJM’s substance abuse. They were also personal friends.

On the morning of 8 July 2012, SJM, aged 57, became drowsy and confused, and began to slur his words. He went back to bed, and his wife checked on him intermittently. By midday, his wife discovered that he was not breathing, and called the Queensland Ambulance Service (‘QAS’) before commencing resuscitation.

SJM was unable to be revived, and was declared deceased at 1230 hours.

Evidence of the Parties

Evidence of Dr JB, general practitioner

  • SJM had been prescribed Doloxene because it controlled his back pain, he was familiar with the medication, non-steroidal anti-inflammatory medications were ineffective in controlling his symptoms, and the other options tried had side effects and may have irritated his liver.
  • SJM had given up regular drinking “a long time ago”.
  • SJM was usually prescribed the equivalent of 180 tablets per month, with two repeats to minimize excessive use. Medication dependency was discussed during each consultation.

Evidence of the Clinical Forensic Medical Unit

  • It appears that Dr JB was aware that SJM was prone to dependency and abuse with prescribed medications and that he had abused alcohol in the past.
  • Doloxene has a maximum dosage of 600mg (6 tablets) per day. It has a long half-life, making it dangerous for chronic use as it increases the risk of a toxic reaction, even at the recommended dosage. It is associated with abuse.
  • Dr JB prescribed SJM with Temazepam for over 13 years. Even at the recommended dose, the use of such drugs can lead to physical and psychological dependence.
  • Doloxene is also contraindicated for patients who are prone to dependency or use of alcohol in excess.
  • On 6 occasions during 2010, Dr JB prescribed SJM Doloxene and/or Temazepam without a consultation, within days of a documented consultation where a prescription had already been issued for these drugs. This occurred on 7 occasions during 2011.
  • Upon review of Dr JB’s clinical records, there was no evidence that SJM had been recommended any additional therapies or alternatives for his pain, such as physiotherapy.
  • No prescriptions for Doloxene, Temazepam, Alprazolam or Zolpidem were recorded in SJM’s PBS Patient Summary, indicating that these prescriptions were by way of private prescription.


  • Dr JB’s continued prescription of Doloxene to SLM, without further investigation into the cause of his symptoms and in the context of his medical history (namely, his alcohol and substance addiction), was unreasonable in the circumstances.
  • An inquest was not warranted – it is unlikely to prevent deaths occurring in similar circumstances.


  • Dr JB’s behavior was referred to the Office of the Health Ombudsman for their assessment and potential disciplinary action.

Chronology of Events

14.05.1999 SJM attended appointment with Dr JB. Complained of difficulties sleeping. Dr JB started prescribing benzodiazepines (Temazepam).
30.07.1999 SJM attended appointment with Dr JB, complaining of post-operative pain following a haemorrhoid operation two days previously. Dr JB prescribed a narcotic pain reliever (Panadeine Forte).
25.03.2002 SJM attended appointment with Dr JB and was prescribed Doloxene fir the first time, following a fracture of his forearm two days previously.
17.07.2007 SJM attended appointment with Dr JB. “Long counselling on dependencies”. Doloxene and Temazepam were prescribed.
19.08.2008 SJM attended appointment with Dr JB. "Basically stopped drinking, using Doloxene as calmative". Doloxene and Temazepam were prescribed.
30.03.2010 SJM attended appointment with Dr JB. Clinical notes read: “psychologically has settled down but takes too many Doloxene”. Doloxene, Temazepam and Panadeine Forte were prescribed.
27.05.2010 SJM attended appointment with Dr JB. Absolute last script for Doloxene”. Prescribed Doloxene, Temazepam and Stilnox.
22.06.2010 Dr JB prescribed SJM Doloxene and Temazepam.
17.08.2010 Doloxene usage averaging eight per day, Temazepam four to six per day, and Stilnox one at night. Dr JB wrote prescription for Doloxene, Temazepam and Stilnox.
29.04.2011 SJM attended appointment with Dr JB. SJM taking 8 Doloxene in the morning, one Zolpidem at 10, and Temazepam six. “Anxiety disorder and substance abuse. Prolong counselling”. Dr JB wrote prescriptions for Zolpidem, Temazepam and Doloxene.
04.02.2012 SJM attended appointment with Dr JB. Clinical notes state “that SJM had problems with medical dependence with Doloxene and Alprazolam”. Prescription for Doloxene was for 1-2 tablets of Doloxene four times per day (an increase from the amount prescribed previously).
21.06.2012 SJM attended appointment with Dr JB. Was prescribed 8 Doloxene per day in divided doses for lower back pain and joint pain, and Temazepam at night for insomnia and stress.
07.07.2012 SJM had a bout of diarrhoea. He had been suffering from the flu and a fever for a few days but, prior to this, had appeared to be getting better.
0745 hours SJM became drowsy during his breakfast, and began to slur his words. He woke his wife up and appeared to be confused. He went back to bed.
1000 hours SJM’s wife checked on him, and he appeared to be sleeping.
1200 hours SJM’s wife checked on him, and he appeared not to be breathing. The Queensland Ambulance Service (‘QAS’) was called, and SJM’s wife began cardiopulmonary resuscitation.
1230 hours QAS paramedics attempted further resuscitation. SJM was unable to be revived and was declared deceased.
Autopsy revealed that the death was due to mixed drugs toxicity, particularly propoxyphene (Doloxene), which was within the reported fatal ranges.