Coroners’ verdicts of methadone poisoning can be misleading: A comparison of coronial verdicts of patients treated with opiate substitution treatment in general practice with conclusions drawn from the clinical records

Records of all patients treated with opiate substitution treatment at Lisson Grove Health Centre dying between 1994 and 2025 and still registered at the time of their death were examined ( N  = 46, over a period of >2000 patient-treatment-years). Additional information was gathered from the Coroner's offices involved, the local toxicology laboratories and the National Programme on Substance Use Mortality. Eight deaths (17%) were considered to be methadone-related by the coroner but after examining the clinical circumstances, in four out of eight the role of methadone was ambiguous.