MJP - Non-inquest findings

OFFICE OF THE STATE CORONER FINDINGS OF INVESTIGATION CITATION: Non-inquest findings into the death of

MJP TITLE OF COURT: Coroner’s Court JURISDICTION: Brisbane DATE: 29 February 2016 FILE NO(s): 2015/3627 FINDINGS OF: Christine Clements, Brisbane Coroner CATCHWORDS: CORONERS: Investigation, mental health, depression, pentobarbitone toxicity

MJP lived in Queensland. She died on 17 September 2015 at her workplace at Red Hill in Queensland. MJP worked as a veterinary nurse. She died due to pentobarbitone toxicity and her death was reported to the coroner. MJP was 27 years of age at the time of her death.

Family MJP’s mother confirmed her daughter suffered with depression which was diagnosed in 2010, although she believed her daughter had suffered from depression prior to this diagnosis. Her mother understood her daughter took prescribed antidepressant medication prescribed by a doctor. She confirmed her daughter was happy in her work as a veterinary nurse since early 2011 and was looking forward to the opportunity of more training to improve her skills.

Apart from her positive work environment her mother also felt MJP had been generally quite happy over the last couple of months. There was a continuing financial pressure regarding outstanding credit card debts.

MJP’s mother was aware MJP had previously attempted to end her life on two occasions. The first occasion was in October 2010. MJP was alone at home and had been drinking, then she cut her wrists and tried to hang herself. She was found in time to be saved. Her mother talked with MJP who referred to the loss of her baby from a previous relationship. MJP was in an unhappy relationship with her former partner at that time.

The second attempt was in April 2011 when MJP cut her wrists. She had been drinking when this occurred. She gave up drinking after this attempt but resumed drinking in the middle of 2014. By the time of her death MJP was drinking weekly with her current boyfriend on Friday evenings. She abstained from alcohol during the week due to her work. It appeared to her mother that MJP was in a good relationship with her current boyfriend.

Boyfriend Her current boyfriend had been in a relationship with MJP since July 2014. He was aware MJP suffered depression and took medication.

On Wednesday, 16 September 2015 MJP completed work and then picked up her boyfriend from his work. They did some shopping at the Indooroopilly shopping centre and then went to Indooroopilly Pig’n Whistle licensed premises for a few drinks, arriving at 5:30pm. They met a friend. They were talking and drinking together until about 9:00pm when MJP received a phone call. Her boyfriend was unaware with whom she was talking. However after that phone call MJP’s mood changed and she appeared and sounded depressed. She started talking about death and specifically about the afterlife. She mentioned she would like to end her life by using Lethabarb, which she said was a euthanasia drug. She asked her boyfriend if he would want to do it with her and he told her it was a bad idea and not to do it. He tried to discuss it with her but she changed the subject.

The conversation then moved on to normal topics and they remained at the Pig‘n Whistle until last drinks were called at about 11:00pm. MJP went to the bathroom but she took a long time and he started phoning her on the mobile but there was no

response. The friend then went to look for her but could not find her. They then went to the car park presuming MJP had gone to the car to sleep, but her car was no longer where she had parked it. He became extremely concerned and they caught a taxi to go to her workplace as he feared the worst. As they were about to get into the taxi he received a text message from MJP. It said ‘I’m sorry, I love you.’ They proceeded to the veterinary practice at Red Hill. A light could be seen from inside the premises and a window was broken to gain access.

MJP’s boyfriend found her in one of the animal cages, sitting with her back against the wall. He saw an IV in her left arm. She had a pale complexion and she was unresponsive. He pulled the IV out from her arm and began calling her name and attempting to get a response from her.

By this time the friend and some other people who had heard the noise had also entered the veterinary practice. A lady commenced cardiopulmonary resuscitation with assistance and instructions from ambulance services by phone. Ambulance officers then took over cardiopulmonary resuscitation attempts when they arrived. Sadly, they were unable to resuscitate MJP, who was declared deceased.

Employer The veterinary surgeon had employed MJP approximately five years earlier, to work as a veterinarian nurse. In her role she had access to the front door as she was required to stay back and lock-up in the evenings and give the animals the final feed and check for the evening.

The veterinary surgeon confirmed with police that Lethabarb is a schedule 4 drug.

Although this medication can be kept in the treatment room it was the veterinary surgeon’s practice to keep the medication in a safe following communication from the Veterinary Surgeons Board and/or Australian Veterinary Association.

MJP was allowed access to Lethabarb during the day, as were other veterinary nurses.

She was trained as a veterinary nurse to use the fluid pump and to place an intravenous cannula. The medication was kept in the safe overnight. MJP did not have permission to access the safe after hours. The key to the safe was kept hidden but MJP must have found out where the key was kept as it had been located in the same place for a long time.

MJP was rostered on as the last person to lock up the surgery on the evening of 16 September 2015.

The veterinary surgeon was completely surprised by MJP’s suicide. When she was first employed he found her a bit stressed but as she gained experience and maturity he considered she was an excellent and capable veterinary nurse and gave no sign that she was suffering from any distress.

The veterinary surgeon was unaware that she was taking antidepressant medication until after her death.

Treating doctor Dr B was MJP’s treating general practitioner from July 2013. Dr B’s records included MJP’s medical history of depression and anxiety, a bleeding disorder (ITP), and a terminated pregnancy due to a tube defect. Dr B treated her for the various health issues including depression from January 2014. The condition had been diagnosed previously by another practitioner. Dr B continued her previous medication of Cymbalta, a SNRI medication for management of her depression and anxiety.

In March 2014, MJP told her doctor she had separated from her (then) husband and she was very upset and unable to focus on work and studies.

The doctor administered a mental health assessment and this indicated moderate to severe mental health issues. A mental health care plan was prepared. At the time MJP’s overall presentation and mood were described as quite flat and quiet. However, the assessment at the time did not indicate any risk of self-harm.

Dr B recommended she commence psychotherapy in addition to prescribed medication. In March 2014, she was referred to a clinical psychologist for psychotherapy sessions.

She continued use of antidepressant medication.

In January 2015, Dr B received a letter from the clinical psychologist confirming MJP had completed four sessions of therapy. She had responded well and made good progress.

In April 2015, MJP reported to her doctor that she had normal sleep, no early morning wakening, had a normal mood, self-esteem and was not suffering from any panic attacks or irrational fears or delusions. She reported no suicidal thoughts and no substance abuse. Dr B continued the prescription of Cymbalta antidepressant medication to maintain her overall mental health.

In May 2015, MJP was very tired. Blood tests were normal but further investigations were arranged. By June 2015, MJP reported that she was feeling quite emotionally good.

She consulted Dr B on three further occasions in July, August and finally on 3 September 2015. These consultations were with respect to oral contraception and menstrual cycle problems. MJP did not raise any issues regarding her mental health during these last consultations. Dr B considered there was nothing in her presentation which caused concern. In fact, Dr B stated there was nothing in her overall presentation during the whole period the doctor was treating MJP that raised concern that she was at risk of suicide.

Autopsy Autopsy examination was conducted on 18 September 2015 by the forensic pathologist, Dr Milne. There were no signs of injury apart from the intravenous cannula and minor bruise and abrasion. There was no sign of disease process in CT imaging.

Toxicology testing confirmed the presence of pentobarbitone recorded at a level of

97mg/kg. As little as 15mg/kg is considered potentially lethal. The prescribed medication duloxetine was detected. Alcohol was detected and measured at a level of 0.154%.

The pathologist concluded MJP died due to pentobarbitone toxicity. It was noted there was also a significant amount of alcohol which may have contributed to death directly, or to the circumstances leading up to her death.

Conclusion MJP had a significant history of depressive illness. She had been treated with antidepressant and psychotherapy support. In the months leading to her death her family and employer considered her to be in good health and not at risk of suicide.

She had however disclosed to her boyfriend that she was thinking of suicide from time to time and that she had considered a way to end her life. He tried to counsel her against this.

There had been two previous occasions when MJP had attempted suicide.

Significantly, on both these occasions her mother recalled that she had been drinking alcohol.

On the evening she died MJP had been drinking alcohol in company with her boyfriend and another friend. As the evening progressed she appeared to become depressed and voiced thoughts of suicide. Her post-mortem blood alcohol level revealed a significant amount of alcohol measured at 0.154%. The prescribed medication duloxetine (Cymbalta) has a warning with the medication to be careful when drinking alcohol whilst taking the medication. The combination can cause liver damage.

Drinking alcohol with the medication might also cause dizziness or drowsiness.

It is not considered necessary to convene an inquest. The Veterinary Surgeons Board and the Australian Veterinarian Association have issued warnings to veterinary practices advising them to keep pentobarbitone safely locked away.

Findings required by s. 45 Identity of the deceased – MJP How she died – MJP died due to pentobarbitone toxicity Place of death – Red Hill Date of death– 17 September 2015 Cause of death – Pentobarbitone toxicity.

Christine Clements Brisbane Coroner Brisbane 29 February 2016