Finding into death of Joeanne Maree Brady

FORM 37 © Rule 60(1)

) FINDING INTO DEATH WITH INQUEST Section 67 of the Coroners Act 2008 Court reference: 1816/07

Inquest into the Death of JOLANNE MAREE BRADY

Delivered On: 14 January, 2010

Delivered At: Melbourne

Hearing Dates: 14 January, 2010

Findings of: JOHN OLLE Representation: -Mr Hutchinson for the family

Mr Richardson for Dr Kinloch Place of death: 35 Brownbill Road, Garfield, Victoria 3814

SCAU: Senior Constable King Taylor

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FORM 37 Rule 60(1)

FINDING INTO DEATH WITH INQUEST . Section 67 of the Coroners Act 2008 Court reference: 1816/07 In the Coroners Court of Victoria at Melbourne

I, JOHN OLLE, Coroner having investigated the death of:

Details of deceased;

Surname: BRADY ; Firstname: JOEANNE Address: 35 Brownbill Road, Garfield Victoria 3814

AND having held an inquest in relation to this death o on 14th January. 2010 at Melbourne

find that the identity of the deceased was J OEANNE MAREE BRADY and death occurred on 15th May, 2007

at 35 Brownbill Road, Garfield, Victoria 3814 from

Ja. MIXED DRUG TOXICITY

(METHADONE, OXYCODONE, HYDROMORPHONE, MIRTAZAPINE, DIAZEPAM AND PROMETHAZINE)

in the following circumstances:

1. Joeanne Brady was aged 39 ycars at the time of her death. She lived with her family at 35 Brownbill Road, Garfield. :

2: An inquest brief has becn prepared by Senior Constable Hichorn of Pakenham Police. Mrs Brady’s husband, Gavin, explained that she had suffered a work accident approximately 10 years earlier in circumstances in which she had been lifting bags of flour, slipped and fell backwards striking her head. Over the ensuing years, despite a number of medical procedures, her condition deteriorated. Mr Brady estimates that Mrs Brady underwent approximatcly 12 operations in a 10 year period. :

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Dr Kinloch

3. Dr Bruce Kinloch, Consultant Physician in pain medicine and rehabilitation, has. provided statements which form part of the inquest brief. . In addition, he gave evidence before me: Mrs Brady first consulted him in February 2003 at the request of her treating neurologist:

"Since that time, she had had recurrent severe headaches which were considered consistent with a diagnosis of migraine. She experienced one or two episodes a week. The headaches were unresponsive to conventional acute and preventative migraine medications and she had

been using narcotic analgesics to control the pain." Treatment offered by Dr Kinloch: "T offered her an intravenous Ketamine infusion to see whether this would provde improved _pain control and the first of these was administered at Epworth Hospital 3/3/2003 to "7/3/2003, There was considerable pain reduction, with a three-month duration. Since that time these infusions had been repeated on the following dates: June 2003, October 2003,

March 2004, August 2004 December 2004, June 2005, June 2006, December 2006.

In February 2007 she was taking Oxycontin 30mg twice daily and using Dilaudid injectable Img two to three times a week. There was almost no movement in her jaw."

Consultation of 11th May, 2007

4. The focus for the inquest was the consultation on’ 11th May 2007 which resulted in the replacement of Oxycontin with Methadone.

5, Dr Kinloch explained:

• "When I reviewed her in my rooms 11/5/2007 she was in severe pain. I felt that changing over from Oxycontin to Mcthadone could be beneficial for her type of neuropathic pain. I prescribed Methadone 10mg tablets 2 twice daily to replace the Oxycontin 30mg twice daily

and | wrote to Dr Barbara Innes, her General Practitioner.”

6. Inhis subsequent statement, Dr Kinloch stated:

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"When she saw me on 11/5/2007 she complained of a significant increase in migraine and changing from Oxycontin to Methadone. My hand written notes are as follows: ‘Cease Oxycontin. Commence Methadone 10mg 2 BD.’"

Dr Kinloch gave frank evidence

7. Dr Kinloch is confident he explained to Mrs Brady that Methadone was prescribed in replacement of Oxycontin. In hindsight, he acknowledged Mrs Brady may not have understood she was to immediately cease Oxycontin.

8. Having heard the evidence of Dr Kinloch, it is apparent that the tragic death of Mrs Brady has caused him to carefully review the manner in which he conveys information to patients. | have no doubt Dr Kinloch was a caring, thorough medica! practitioner. The best interests of Mrs Brady were paramount to Dr Kinloch.

9, He wrote to Mrs Brady’s general practitioner, advising her of the crucial change in narcotic medication, Ordinarily, he would write to his patient, explaining the change. Dr Kinloch could not explain his failure to write to Mrs Brady.

10, At May, 2007 it was not his practice to make notes of conversations with patients.

Lessons Jearnt by Dr Kinloch

11. Mrs Brady misunderstood she was to cease Oxycontin. After the consultation, she told her husband that Methadone would be added to her medication regime.

12. It was not Dr Kinloch’s practice to warn patients of the potential fatal consequences of combining narcotic medication. He could not explain why. It was however an atypical circumstance in his experience to replace Oxycontin with Methadone.

Dr Kinloch now warns patients of the fatal risks

13, Subsequent to the death of Mrs Brady, Dr Kinloch clearly states the fatal risk of combining narcotic medications, He ensures they understand.

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14. Dr Kinloch considered that a warning on the box of dispensed medication would be beneficial. Also, doctors could provide patients with a note, highlighting the fatal risks, at the consultation. If so, when Mr Brady questioned his wife about the alteration in medication, she could have referred to the note of Dr Kinloch, clearly stating that Methadone was prescribed in replacement of Oxycontin. :

Was hospitalisation a preferred option?

15. Under cross-examination, Dr Kinloch conceded in hindsight, the better course would have been to hospitalise Mrs Brady for the high risk period of changing over from Oxycontin to Methadone. His final position however, was that hospitalisation would not have been warranted,

• had Mrs Brady ceased Oxycontin upon commencing Methadone. :

Overview of evidence

16. Dr Kinloch could not recall the conversation he had with Mrs Brady on the 11th May 2007.

He is confident, however, he would have told her to cease Oxycontin.

"17. Mr Brady explained:

"[ picked her up from the Garfield train station, Soon after I picked her up she. commented to me that the Doctor had given her a prescription for Methadone, which was a stronger pain killer. She seemed concerned that it was a stronger medication, I was concerned as well. I asked her if she still had to take her other medications. She replied to me "Yes? she did, she

said she thought this was strange but trusted the Doctor. I recall she expressed her concern |

about taking the Mcthadone and the tablets but she said the Doctor was clear that was what she had to do."

• 18. Mr Brady explained that she commenced taking Methadone immediately and he noticed that she was "very lethargic”.

"There were times prior to this that she also was a bit lethargic but with the methadone it was more pronounced, Prior to taking the methadone she would have lethargic days but she would read a book or watch telly or a dvd,"

19. Mr Brady noted that his wife spent most of the day sleeping and the following day, Sunday 13th May, was Mothers Day. On Monday, 14th May, she felt unwell. Mr Brady took his son for an outing and returned about 5.00pm. Mrs Brady was sleeping heavily on his retum and, upon later checking her at 10.30pm, she continued to sleep heavily. In the following day, Mr Brady found his wife deccased.

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Expert Opinion

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20. Expert statements have been obtained by Professor Olaf Drummer. Professor Drummer has | reviewed the inquest brief and various statements, in particular Dr Bruce Kinloch. In essence,

Professor Drummer explained that the toxicological analysis, post mortem:

"shows the presence of Methadone, which she presumably started somewhere from the date of the permit 11th May to the night of her death on 14th May."

21, Professor Drummer observed the prescriber’s intention was for Mrs Brady:

".,, to cease Oxycondone and replace this with Methadone. On the assumption she started Methadone on the 11th or 12th May, this would: have allowed sufficient time for her oxycodone (from Oxycontin) taken on or before this time to have been completely removed by her body by the 14th May. Since oxycodone was present in her blood in concentrations consistent with therapeutic use, it is possible that the deceased continued her oxycodone whilst starting methadone."

The danger period 22, Professor Drummer explained: "If methadone is to replace another drug such as Oxycodone, there can be a danger period when the replaced drug is still present in the body, or if the patient does not stop taking the ‘replaced’ drug. Too much narcotic analgesic can produce respiratory depression leading to coma and death, almost always when the patient is sleeping. Pulmonary oedema can occur from respiratory depression. Effects of excessive opioids on the bladder can also lead to . difficulty in micturition and a build up of urine in the bladder (present in the deceased)."

23. And further: "It is my view that the use of methadone could have contributed to her death in the circumstance that oxycodone was either still present in her body or she was still consuming

this drug, in the presence of recent use of hydromorphone."

24. Professor Drummer concluded:

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"In summary, it is my view that her death was probably caused by the combined use of the narcotic analgesics in combination with promethazine but her death is likely to have been precipitated by the addition of methadone to her current regime.”

Overview

25. The evidence of Dr Kinloch was frank and impressive. A review of his file has revealed he offered Mrs Brady professional care and attention. Further, his clinical decisions on 11th May, 2007 were sound.

26: Dr Kinloch intended Mrs Brady to cease Oxycontin and commence Methadone. The toxicological analysis and evidence and statements of Professor Olaf Drummer indicate that Mrs Brady used Oxycontin and Methadone following the consultation with Dr Kinloch on the 11th May, 2007.

27. Mrs Brady told her husband that she was to add Methadone to her medication regime. She made no mention of ceasing Oxycontin.

28. Iam satisfied it was the intention of Dr Kinloch that Mrs Brady cease Oxycontin upon commencing Methadone. I am satisfied that she misunderstood. Immediately following the consultation, she filled her Methadone prescription.

29. Thereafter, Mrs Brady ingested both Oxycontin and Methadone. Dr Kinloch commenced Mrs Brady on a relatively low dose of Methadone. Had Mrs Brady ceased Oxycontin, it is unlikely: she would have suffered respiratory depression. :

. Medical Examination °

30. On the 17th May, 2007 Dr Matthew Lynch, Forensic Pathologist at the Victorian Institute of Forensic Medicine performed an autopsy.

31. Dr Lynch found the cause of death to be mixed drug toxicity (Methadone, Diazepam, Mirtazapine, Oxycodone, Promethazine and Hydromorphone)

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RECOMMENDATION .

Pursuant to section 72(2)-of the Coroners Act 2008, I make the following recommendation connected with the death:

1. That the Pharmacy Board of Victoria direct pharmacists to place warnings on narcotic

medication, highlighting the fatal risks associated with combining narcotic medication.

Johth Olle Coroner . Date\ g March 2010

Distribution

Pharmacy Board of Victoria

Medical Practitioner’s Board of Victoria Drugs & Poisons Unit, DHS

Minister, DHS

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