Deceased
Kenneth Agnew
Demographics
37y, male
Coroner
Coroner John Olle
Date of death
2007
Finding date
2012-04-30
Cause of death
combined ethanol and drug toxicity
AI-generated summary
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include: Dr Lum, the facility doctor, was unaware of Mr Agnew's methadone prescription and heavy alcohol use despite the care team documenting excessive drinking and warning of dangerous interactions. Dr Lum altered psychotic medications and referred to a liver specialist without informing Mr Agnew's general practitioner, Dr Kavanagh. The failure to communicate Mr Agnew's complete medication history and substance use between care providers, combined with lack of coordination between the facility doctor and GP, created a dangerous prescribing environment. Clinicians prescribing psychotropic medications must obtain complete medication histories, be aware of substance use, and communicate changes with all treating doctors. Aged care facilities must ensure all treating clinicians have access to relevant care plans documenting substance abuse concerns.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Form 37 Rule 60(1) Section 67 of the Coroners Act 2008
Inquest into the Death of KENNETH AGNEW
Delivered On: 30 April 2012 Delivered At: Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne Victoria Hearing Dates: 14 October 2009 Findings of: JOHN OLLE, CORONER Police Coronial Support Unit: Leading Senior Constable Hose
lof5
Court Reference: 5107/07
"Kenneth still drinking heavily in his room,”
"Manager told him not to drink in his room, otherwise there would be potential fatal side-effects
alongside his medication."
Agnew.
Dr Lum had access to the Ferntree Manor file in which she made the entry referred to above.
Mrs Sui acknowledges that Dr Lum would have not ordinarily read the Care Plan when making
his entries in the Progress Notes section of the file.
Dr Lum
Ordinarily, he would only consult residents who did not have a general practitioner. He made an exception in the case of Mr Agnew whom he treated for minor complaints. He acknowledged, however, on several occasions he altered Mr Agnew’s psychotic medication and also referred him to a Liver
Disease Specialist.
practitioner. He accepted he should have, 17, Dr Lum:
e Didn’t know the deceased was on a methadone program
« Didn’t know the deceased abused alcohol
° Says he would have been very concerned about both methadone and alcohol abuse, had he known and would not have altered his medication. He would have insisted Mr Agnew return to his general practitioner
© Ho should have advised Dr Kavanagh he altered the medication regime, and that he referred Mr Agnew to a liver specialist
e Agrees that general practitioners who are licensed to prescribe methadone must access a full history
of medications being prescribed.
18, in this case:
30f 5
"This 37 year old male, Kenneth Agnew, died from the combined toxic effects of ethanol and a number of drugs including methadone and benzodiazepines. The deceased had underlying positive hepatitis. C serology. This is seen in association with chronic intravenous drug abuse. There was
also marked fatty change of the liver.
No other significant natural disease was identified.”
Finding
I find the cause of death of Kenneth Agnew to be combined ethanol and drug toxicity.
I direct that a copy of this finding be provided to the following:
Senior Next of Kin
Dr Lum
Dr McRae
Ms Li Ling Sui
Mr Stephen Lanini, Eastcare (Salvation Army).
Signature:
JOHN OLLE CORONER f
Date: 30 Api,
2 Page 6, Post Mortem report
5 of 3
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