Finding into death of James

IN THE CORONERS COURT

OF VICTORIA AT MELBOURNE

Court Reference:

REDACTED FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(7) Section 67 of the Coroners Act 2008

(Amended pursuant to Section 76 of the Coroners Act 2008 on 7 May 2012)

Inquest into the Death of JAMES

Delivered On:

Delivered At:

Hearing Dates:

Findings of:

Representation:

15 February 2012

Coroners Court of Victoria Level 11, 222 Exhibition Street Melbourne, Victoria 3000

21 December, 2011

JOHN OLLE

Mr Ron Gipp, Department of Health

Police Coronial Support Unit: Leading Scnior Constable Tania Cristiano

11 of 20

5181/09

_I, JOHN OLLE, Coroner having investigated the death of JAMES

AND having held an inquest in relation to this death on 21 December, 2011 at Melbourne

find that the identity of the deceased was JAMES born on I July, 1985

and the death occurred on 31 October 2009

at Unit 8/158 Napier Street, Essendon, Victoria 3040

from: la, COMBINED DRUG TOXICITY (MORPHINE AND DIAZEPAM)

in the following circumstances:

PURPOSES OF A CORONIAL INVESTIGATION

1, The primary purpose of the coronial investigation of a reportable death? is to ascertain, if possible, the identity of the deceased person, the cause of death and the circumstances in which the death oceurred.$ The practice is to refer to the medical cause of death incorporating where appropriate the mode or mechanism of death, and to limit investigation to circumstances sufficiently proximate and causally relevant'to the death.

2. Coroners are also empowered to report to the Attorney-General on a death they have investigated; the power to comment on any matter connected with the death, including matters relating to public health and safety or the administration of justice; and the power to make recommendations to any Minister, public statutory or entity on any matter connected with the death, including recommendations relating to public health and safety or the administration of justice.”

3. The focus of a coronial investigation is to determine what happened, not to ascribe guilt, attribute blame or apportion liability and, by ascertaining the circumstances of a death, a coroner can identify opportunities to help reduce the likelihood of similar occurrences in future.

BACKGROUND

4. James was aged 24 years at the time of his death. The coronial bricf has fully addressed the

circumstances of James’ death.

5. At inquest on 21 December, 2011, a summary of evidence was read to the court.

6. James lead a troubled existence, suffering depression, anxiety, and insomnia, He developed an

addiction to prescription medication he was unable to satisfy or overcome,

5 Section 4 of the Act requires certain deaths to be reported to the coroner for investigation. Apart from a jurisdiction nexus with the State of Victoria, the definition of a reportable death includes all deaths that appear "to have been uncxpecicd, unnatural or violent or to have resulted, directly or indirectly, rom accident or injury.” 6 Section 67 ol the Act.

Sections 72(1), 72(2) and 67(3) of the Act regarding reports, recommendations and comments respectively.

12 of 20

Prescription Shopping

7. James addiction to prescription medication saw him attend numerous doctors. James’ former partner recalls a normal day for James would involve prescription shopping for several hours during the morning and carly afternoon. James would then attend work, return home and consume large quantities of medication during the late evening. Each day the cycle would repeat.

8. In the three years prior to his death, records disclosed that James had attended 19 different doctors who prescribed him medications through the PBS. The medications were dispensed at 32 different pharmacies, Further, there was evidence that James had obtained large quantities of medications that were not recorded on PBS.

9. James’ family and friends were aware of his addiction. His addiction resulted in several episodes of violent behaviour, relationship breakdown and job loss.

10. Noting his addiction was harmful, to his credit, James undertook active measures to minimise the harm. He stored his drugs in a secure cabinet which a friend would attend each evening to lock and remove the key until morning. In addition, James attended residential drug and alcohol rehabilitation programs.

{1.- In the month prior to his death James’ depression and prescription drug abuse reached a point in which his performance at work was adversely affected. Unsurprisingly, he lost his job. Financial problems ensued.

12. Despite love and support of family and friends, James was unable to overcome his addiction.

Concerned for his welfare, his father arranged for police to conduct a welfare check. James was found deceased. Notes written by him indicate his decision to end his life. He expressed love for family

members.

13, No-one should feel responsible for James decision to end his ltfe.

Post Mortem Medical Examination

14. On the 4th November, 2009, Dr Michael Burke, Forensic Pathologist at the Victorian Institute of Forensic Medicine, performed an autopsy on the body of James.

15. Dr Burke found the cause of death to be combined drug toxicity (morphine and diazepam). Dr

Burke commented:

"Mr James was «24 year old man who, according to the circumstances as detailed in the Victoria Police report of death Form number 83, was located hy police after his father had requested « welfare check. The deceased was located in bed. Many prescription drugs were located in the flat and a used syringe on the bedside drawer. There were no visible injuries to the body and no

nyection marks, Suicide notes were located in the flat. There were no suspicious circumstances,

13 of 20

The post-mortem examination showed no evidence of any injury that would have contributed or led to death.

There was no evidence of any natural disease process that would have contributed or led death(sic).

Toxicological examination showed the presence of morphine within blood. No 6 monoacetyl morphine was identified. Morphine can be present from the use of morphine or heroin, In addition, a raised level of diazepam. Citalopram and alprazolam (antidepressant medication), quetiapine and naproxen were identified,"

16. I consider there ave lessons to be learnt from an analysis of the circumstances of James’ death. I thank the parents of James for their support of my investigation.

Real Time Prescription Monitoring

17. None of the 19 doctors or 32 pharmacists involved in James’ care, had the benefit of real time prescription monitoring, The circumstances of James’ death highlight the urgent need for real time

prescription monitoring.

18. In particular, the medical practitioners whom James consulted were denied an opportunity to exercise clinical judgement with the benefit of the complete clinical picture.

Acknowledgement

19. thank the organisations and individuals who have assisted me with my investigation into James’s death and the issue of prescription shopping. I am particularly grateful to those who have provided submissions to the court regarding real-time prescription monitoring; these have been invaluable for me in understanding what the hurdles are, and what we might be able to do about them,

Definitions

20. For the purpose of this finding, T understand the term ‘prescription shopping’ (often referred to as ‘doctor shopping’) to describe the practice whereby a patient attends multiple doctors in order to obtain prescriptions for controlled drugs in excess of therapeutic need, which are then used for personal consumption or on-sold to others, The patient usually conceals {rom cach doctor the fact that he or she

is attending other doctors to obtain these prescription medications,

The need for real-time prescription monitoring in Victoria

8 Conments section, Dr Burke’s report.

14 of 20

21. The most striking aspect of the submissions I received, as well as the copious position statements and reports and other public documents I reviewed, is that in principle everyone agrees that Victoria needs a real-time prescription monitoring program. The need is highlighted by the Victorian Government, the Commonwealth Government, the Victorian Alcohol and Drug Association, the Royal Australasian College of Physicians, the membcr organisations of the National Pain Strategy, the Pharmaceutical Society of Australia, the Pharmacy Guild of Australia, the Public Health Association of Australia, my fellow coroners, and the individual members of the community who wrote submissions for me to consider, There is universal concern at the harm and death caused by prescription drug diversion and misuse, and a universal desire to put a halt to it.

22, Given this universal support, I am not surprised at the frustration and disappointment that has been expressed in the community, regarding the lack of concrete progress towards implementing realtime prescription monitoring. However, having considered a wide range of submissions and other material, I can understand how this situation of apparent government inaction has come about. There are many complex issues that must be considered, including:

• how a real-time prescription monitoring program should be funded;

• where the data should be stored;

• what format the data should be stored in;

• who should have access to the data and under what circumstances; and

• the ramifications of introducing real-time prescription monitoring, for health services such as drug and alcohol services and pain management services,

23. None of these issues present an insurmountable obstacle, and I note that in the past few days there have been several encouraging signs that finally action is under way, including an indication that the Australian Government Department of Health and Ageing will implement a national real-time recording and reporting system for prescription medications by July 2012,

24. Before making my recommendations, | will address briefly the major issues concerning realtime prescription monitoring that have been brought to my attention in the submissions.

Capacity to implement a program

25. In the material I have considered, there is overwhelming agreement that the capacity exists right now ~- and has in fact existed for some years - to implement a real-time prescription monitoring program in Victoria, The necessary infrastructure is in place, including internet-connected computers installed at practically every prescribing and dispensing point throughout Victoria. The software solutions also exist, including software packages developed by independent vendors. There are no technical barriers to

Victoria introducing real-time prescription monitoring.

rsus Victorian program

15 of 20

26. Most of the submissions T have reccived express either directly or indirectly a desire that any real-time prescription monitoring program be implemented nationally rather than only in Victoria, 1 particularly note the Victorian Department of Health’s assertion that Commonwealth prescription monitoring initiatives "would form an integral part of the information and communication technologies solution" for any Victorian program. In the absence of any contrary evidence, I accept these submissions and agree that a national real-time prescription monitoring program would be the most

desirable outcome.

27. I further note the submission dated 18 January 2012 that I received from the Australian Government Department of Health and Ageing, confirming that under the auspices of the Electronic Reporting and Recording of Controlled Drugs initiative it has licensed software from Tasmania that will enable real-time prescription monitoring, The Australian Government Department of Health and Ageing is aiming to modify and implement the software by July 2012, so the states and territories can go ahead with introducing real-time prescription monitoring programs, The Australian Government Department of Health and Ageing has subsequently reiterated this commitment in public announcements.

28. The Victorian Department of Health submitted to me in the summary inquest held on 21 December 2011, that after the Australian Government Department of Health and Ageing implementation is complete it will introduce a Victoria-wide real-time prescription monitoring system.

29, L welcome this indication that state, territory and federal health authorities are working together to address prescription shopping. However, I have some concer about the Victorian Department of Health tying its actions to the Australian Government Department of Health and Ageing initiative.

30, A particular concern is what might happen in Victoria if the Australian Government Department of Health and Ageing does not meet its self-imposed July 2012 deadline. Government information technology infrastructure projects can sometimes encounter unexpected delays. Tt would be regrettable if the Victorian Department of Health is waiting for an extended period or even indefinitely while preventable harms and deaths from prescription shopping continue to occur.

31. It is important the Australian Government Department of Health and Ageing’s information technology infrastructure might not deliver all the features that an effective real-time prescription monitoring system requires. In this respect, J note that at the 21 December 2011 summary inquest, the Victorian Department of Health submitted that the Tasmanian real-time prescription monitoring system has several flaws; at present it apparently only works in real-time for prescribers within the ‘Tasmanian

public health system, and not all dispensers are covered.

Scope of drugs monitored

32. 1 have considered the diverse submissions I received on what drugs should be monitored in a

Victorian real-time prescription monitoring program, and have conchided that all prescription drugs should be monitored. | note some organisations and individuals have submitted that when current legislation and regulation is taken into account the most practical solution - at least initially - is fo

monitor only Schedule 8 drugs. However, 1 further note that the Tasmanian systen being rolled out

16 of 20

nationally under the auspices of the Australian Government Department of Health and Agcing has the capacity to monitor alprazolam and other drugs outside Schedule 8; I take this as an indication that any hurdles to monitoring beyond Schedule 8 can be overcome.

Ramifications of real-time prescription monitoring

33, I acknowledge the concern expressed in several submissions, that a real-time prescription monitoring program will have profound ramifications throughout the health sector, For example, increased identification of prescription shoppers who have developed dependence on medications may lead to increased referrals to drug and alcohol services that may not have capacity to deal with them.

Similarly, where patients are engaging in prescription shopping behaviour to manage chronic pain and attendant opioid addiction, they may need to be referred to pain specialists for treatment, and these specialists may not be resourced to cope with an influx of new complex patients.

34, For this reason, I have formulated a recommendation regarding a steering committee to oversee the implementation of real-time prescription monitoring in Victoria. The steering committee would

include representatives from the various health sectors that may be affected,

Point of recording for prescription information

35. At the directions hearing for this summary inquest, I indicated that a Victorian real-time prescription monitoring program would need to monitor both the dispensing and prescribing of medications. I subsequently reccived a submission from the Victorian Department of Health, explaining that medications would only need to be recorded at the point of dispensing, not the point of prescribing.

I also received a competing submission that if the system only captures information at the dispensing end of the process, doctors will not be engaged sufficiently in the prescription monitoring process and most responsibility for prescription monitoring will be shifted onto dispensers.

36, 1 find the latter argument compelling. I reiterate my view that information should be captured both at the point of prescribing and at the point of dispensing, T consider doctors should have access to accurate, up to date information in the exercise of clinical judgement. Patients best interests must be

served if doctors are appraised of the full clinical picture.

37. At the directions hearing on 1 August 2011, I defined a real-time prescription monitoring

program as follows:

[.... ] a program that gathers information on medications immediately as they are prescribed and/or dispensed. The information is stored in a central electronic database where it can be acccssed immediately by medicine prescribers and dispensers, to assist in determining whether a patient ts

attempting to obtain medicines in excess of medical need.

38. On the basis of the advice and submissions 1 subsequently received, an effective real-time

prescription monitoring program for Victoria should include the following features:

17 of 20

• The primary focus and intent of the program must be lo improve public health, not enforce laws.

Where prescription shoppers are identified, they should in the first instance be directed to support services, with law enforcement only involved with persistent shoppers and/or shoppers who are motivated by profit rather than drug dependence. .

• The Victorian program should be administered by the Victorian Department of Health, even if the information technology infrastructure is hosted at a federal level,

• The program must monitor all prescribing and dispensing of prescription drugs.

• The program must support (rather than usurp) physicians’ prescribing decisions and pharmacists’ dispensing decisions. Physicians and pharmacists must retain discretion to treat clients as they believe is appropriate.

• The Victorian Department of Health must monitor prescribing and dispensing behaviour captured

hrough the program, to identify any behaviours of concern.

• The program must provide universal coverage for prescribers and dispensers, including in general

practice, in public and private hospitals, in community pharmacics and hospital pharmacics, in

emergency departments, and anywhere else controlled drugs are prescribed and/or dispensed.

• ' The program must include some mechanism or tool to support physicians’ and pharmacists

prescribing decisions in the face of any client objections.

RECOMMENDATIONS: Pursuant to section 72(2) of the Coroners Act 2008, 1 make the following recommendation(s)

connected with the death: Imake the following recommendations to support this real-time prescription monitoring program.

Recommendation 1

The Victorian Department of Health implement a real-time prescription monitoring program within 12 months, in order to reduce deaths and harm associated with prescription shopping. The program should include the following functionality: (a) a primary focus on public health rather than law enforcement;

(b) recording of all prescription medications that are prescribed and dispensed throughout Victoria without exception; (c) provision of real-time prescribing information via the internet to all prescribers and dispensers throughout Victoria without exception; (d) a focus on supporting rather than usurping prescribers’ and dispensers’ clinical decisions; and (e) facilitating the ability of the Victorian Department of Health to monitor prescribing and dispensing to identify behaviours of concern.

Recommendation 2 The Victorian Department of Health convene a steering committec to oversee the implementation of the

real-time prescription monitoring program in Victoria, Membership should include representatives from prescribing and dispensing peak bodies, and the pain management and drug and alcohol sectors.

18 of 20

The Victorian Department of Health devclop a contingency plan to implement a Victorian-based realtime prescription monitoring program in the event that the anticipated Australian Government Department of Health and Ageing information technology infrastructure for electronic recording and reporting of controlled drugs is delayed more than six months beyond the declared July 2012 deadline,

Recommendation. 4

The Victorian Department of Health develop a contingency plan to implement a Victorian-based realtime prescription monitoring program in the event that the anticipated Australian Government Department of Health and Ageing information technology infrastructure does not support the following functionality: (a) a primary focus on public health rather than law enforcement; (b) recording of all prescription medications that are prescribed and dispensed throughout Victoria without exception; (c) provision of real-time prescribing information via the imtemet to all prescribers and dispensers throughout Victoria without exception; (d) a focus on supporting rather than usurping prescribers’ and dispensers’ clinical decisions; and (c) facilitating the ability of the Victorian Department of Health to monitor prescribing and dispensing to identify behaviours of concern.

Finding I find the cause of death of James to be mixed drug toxicity (morphine and diazepam) in circumstances

in which he intentionally took his own life.

Signature:

JOHN OLLE | CORONER | 16 February 2012 As ebruary, 2012

I direct thal a copy of this finding be distributed to the following party for action:

Victorian Departmcut of Health,

19 of 20

Additionally, I also direct that this finding be distributed to the following parties for their information only:

• Jane Halton PSM, Secretary, Australian Government Department of Health and Ageing.

• The Hon. David Davis, Minister for Health Victoria.

• The Hon Tanya Plibersck MP, Minister for Mealth Australia.

• Stephen Marty, Registrar, Victorian Pharmacy Authority.

• Lynelle Briggs, Chief Executive Officer, Medicare Australia,

• Kos Sclavos, National President, Pharmacy Guild of Australia.

• Dr Adrian Reynolds, Clinical Director, Alcohol and Drug Services, Tasmanian Department of Health and Human Services.

• Sam Biondo, Executive Officer, Victorian Alcohol and Drug Association.

• Dr Malcolm Hogg, Department of Anaesthesia and Pain Management, Royal Melbourne Hospital.

• Dr Daniel Lec, Pain Management Services, Royal Melbourne Hospital,

• Dr Tan Colclough.

• Mr Bill Suen, Victorian Branch Director, Pharmaceutical Society of Australia,

• Ms Emma Cunningham, Victoria State Manager, Royal Australasian College of Physicians.

• Dr Harry Hemley, Victoria President, Australian Medical Association.

20 of 20