OCC Inquest - Stoyka 2019
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Patrick
Held at: 45 Main St. E., Hamilton
From: June 10, 2019
To: June 12, 2019
By: Dr. Jennifer Tang
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Patrick Stoyka
Date and time of death: January 27, 2018 at 4:20 p.m.
Place of death: St. Catherine's General Hospital
Cause of death: Multi organ failure, acute methadone toxicity
By what means: Suicide
(Original signed by: Foreperson)
The verdict was received on June 12, 2019
Coroner's name: Dr. Jennifer Tang
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
To the Ontario College of Pharmacists:
- Explore the implementation of the following as standards of practice for Ontario community pharmacies:
- Methadone must be stored in a locked unit when not in immediate use.
- Methadone prescriptions must be prepared in an area that is not accessible and not in full view of patients or other members of the public.
- Where repackaging of methadone occurs, all containers must be relabeled with the name of the medication, concentration, manufacturer, lot number, and expiry date as per Drug and Pharmacies Regulation Act standards.
- Support and encourage Ontario community pharmacies to create an emergency preparedness plan for situations including but not limited to opioid overdose.
To Health Canada and the Ontario College of Pharmacists:
- Explore the feasibility of increasing the frequency of reconciliation of narcotics to more than every six months as is the current requirement.
To the Ontario College of Pharmacists and the Institute for Safe Medication Practices Canada:
- To collaborate on issuing a safety bulletin for publication in Pharmacy Connection and/or other similar paper or online publications so that lessons learned from the death of Mr. Stoyka may be widely distributed to prevent future similar deaths.