Coroner's Court of Western Australia

Inquest into the Death of Geoffrey Mark REID

Inquest into the Death of Geoffrey Mark REID

Delivered on :28 June 2016

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

I recommend that the Department of Health give consideration to amending the current operational directive OD 0598/15 to cover all use of methadone in a hospital setting, whether as an opioid substitute or otherwise. In particular, the directive should include information about the specific risks associated with commencing or re-commencing a patient onto methadone with guidelines on how such a patient is to be safely managed.


I recommend that the Department of Health and/or the Mental Health Commission give consideration to funding and placing an Addiction Medicine Consultant within the Alma Street Centre to ensure that the goal of integrating mental health and drug and alcohol services is progressed.


I recommend that the Department of Health give consideration to funding and facilitating CPOP training for psychiatrists based within the Alma Street Centre.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was 23 years of age at the time of his death and had struggled with mental health issues as well as addiction issues.  At the time of the deceased’s last hospital admission the main concern for medical professionals was the acute exacerbation of his schizophrenia.  His withdrawal from opiates was a secondary concern, particularly given he was not showing any concerning signs of physical withdrawal.

As part of his future planning, the deceased re-engaged with the methadone program.  Based on his previous history of opioid use, doctors and pharmacists set the doses within safe limits.  Due to an unexpectedly significant reduction in the deceased’s tolerance to methadone within days the deceased was overcome by the toxic effects of the methadone he was prescribed and died while still in hospital.

Evidence at the inquest supported the conclusion that the death of the deceased was entirely unexpected and an extremely rare event for a methadone patient in a hospital setting.  The Court heard that steps have been by Next Step and Alma Street Centre to ensure that this does not occur in the future.

At the inquest expert witnesses suggested some positive changes which could assist in ensuring the safety of mental health patients who have drug and alcohol issues and the Coroner made recommendations relying upon that expertise.

The Coroner found the deceased died on 12 December 2010 as a result of combined drug toxicity and found that the manner of death was by way of misadventure.

Catch Words : Administration of medications to patients during hospital stays : re-induction of methadone use : misadventure

Last updated: 6-Jun-2024

[ back to top ]