A series of medical missteps and a family's dire living circumstances contributed to a six-year-old boy's tragic death after he mistakenly drank his parents' methadone when it had been mixed with orange juice.
The boy, who was referred to in the NSW State Coroners Court only as MO, drank the mixture at his home in the Northern Rivers region of NSW before he died in hospital on August 6, 2018.
His parents, who both suffer cognitive impairment, were on the NSW Opioid Treatment Program and had been prescribed the opioid replacement medication methadone.
The court heard they were allowed to self-administer up to 12 "takeaway" doses each week from their dispensing pharmacy.
The doses prescribed by Paul McGeown, a specialist in addiction medicine whom has since surrendered his registration, were increased in increments described to the court as "excessive", "outside the guidelines" and "significantly higher" than other practitioners.
Several reports had been made to the Department of Community and Justice, formerly known as the NSW department of family and community services, about the welfare of the boy and his siblings.
In 2015, caseworkers described the children's living conditions as "hazardous" and "immediately threatening to their health and safety" while a 2017 report documented the "squalid nature" of the home.
Deputy State Coroner Carmel Forbes said the circumstances culminated in a "high-risk situation" for the young boy.
"Twelve doses of takeaway methadone were going into MO's home each week. His mother had an intellectual disability (and) there is evidence that the house was chaotic ... this was a high-risk situation for MO," she said in findings delivered on Tuesday.
Ms Forbes said a more robust system should be in place for dispensing pharmacies after one of the pharmacists involved in dispensing methadone to the parents admitted she was not aware of the Opioid Treatment Program guidelines.
Although the coroner acknowledged neither the prescriber nor the dispenser had control as to the manner in which takeaway doses of methadone were consumed, she recommended OTP guidelines be reviewed.
An expert committee comprising clinicians with expertise in alcohol and other drugs as well as addiction medicine will be formed this year.
The committee will review the OTP guidelines led by the NSW Health chief addiction medicine specialist, with a draft to be delivered by mid-2024.
Child safety will assume a high priority in the review.
"The upcoming review of the OTP guidelines is an excellent opportunity to consider and ameliorate the very real risks to children of takeaway methadone being brought into the family home," Ms Forbes said.
The parents previously pleaded guilty to a charge of failing to provide for a child, causing danger of death.
Each received a 20-month community correction order.
