Deceased
JOHN CRIVERA
Demographics
31y, male
Coroner
Coroner Dr Jane Hendtlass
Date of death
2006-12-03
Finding date
2013-05-21
Cause of death
Quetiapine toxicity in a man consuming sertraline and mirtazapine
AI-generated summary
31-year-old with bipolar disorder died from quetiapine toxicity while taking sertraline and mirtazapine. He was under a Community Treatment Order and his treating team reduced his antipsychotic dose while he deteriorated between October-November 2006. Critical learning: His team relied solely on patient self-report of medication compliance despite documented non-compliance (retrospective pill counts showed he stopped lithium and valproate around September). When blood tests were ordered in late November, they were optional rather than mandatory, and he didn't attend. If collateral evidence (blood levels) had been obtained in October when concerns arose about mental deterioration, the team would have detected non-compliance, prevented dose reductions, and potentially averted death. This case highlights risks of accepting patient word without objective verification, especially when clinical deterioration contradicts reported compliance.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Court Reference: COR 2006 4595
Form 37 Rule 60(1 ) Section 67 of the Coroners Act 2008
(Amended pursuant to s76 of the Coroners Act 2008 on the 5" September 2013)
Inquest into the Death of: JOHN CRIVERA
Delivered On: 21 May 2013
Delivered At: Level 11, 222 Exhibition Street Melbourne 3000
Hearing Dates: 31 January 2011
Findings of: , JANE HENDTLASS, CORONER
Representation: Ms Foy appeared for Eastern Health
Police Coronial Support Unit Leading Senior Constable King Taylor
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I, JANE HENDTLASS, Coroner having investigated the death of JOHN CRIVERA
AND having held an inquest in relation to this death on 31 January 2011 find that the identity of the deceased was JOHN CRIVERA
born on 31 December 1974
and the death occurred on or about 3 December 2006
at 11 Wynette Street, Upper Ferntree Gully Victoria 3156
from:
1 (a) Quetiapine toxicity in a man consuming sertraline and mirtazapine
in the following circumstances:
John Crivera was 31 years old when he died. He lived as a boarder at 11 Wynette Avenue in
Upper Ferntree Gully. The owner of the property and co-resident was Sandy Pandelias.
Ms Pandelias told the Court that Mr Crivera had lived at her house for five or six months. She
did not get to know him well in that time. She said he was a very very quiet person.
Mr Crivera’s medical history included bipolar affective disorder and abuse of alcohol, amphetamines, cannabis and LSD. Mr Crivera denied that his long-term low libido was associated with childhood sexual abuse. An electrocardiograph performed, on 26 September
2006 did not disclose any abnormality in cardiac function.
Mr Crivera was subject to a Community Treatment Order administered through Chandler House Community Mental Health Service which is part of Eastern Health. His Case Manager was Seigrid Cooke. Ms Cook told the Court:
“(A)s the case manager my role is to monitor people's mental state in the community. To regularly review them, to address any social issues that might possibly have an impact on
their mental state and the stability of their mental state.”
Mr Crivera’s consultant psychiatrist was Dr Nuala Moran. His treating medical officer was Dr Stephen Xu. Dr Xu and Dr Moran prescribed diazepam, quetiapine, lithium, sertraline and sodium valproate. These medications were dispensed by Hawkes Pharmacy. Mr Ctivera was also required to submit to intramuscular administration of 125mg zuclopenthixol deconate
every two weeks at Chandler House.
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Ms Cook expressed the opinion that Mr Crivera seemed to understand that he needed to remain compliant with his medication and that illicit substances had a significant impact on
his illness. Therefore, she believed that he had reasonable insight into his circumstances,
Further, between June and the beginning of October 2006, Mr Crivera continued to manage
his illness quite well:
On 9 June, Ms Cook described Mr Crivera as well, relaxed, pleasant, engagable, with good rapport and euthymic in mood. He admitted to reducing his sertraline dose a month earlier and started a new job as a welder. He was drug and alcohol free and admitted that speed had caused his most recent relapse. He was attending Chandler House regularly and reliably for
his depot injections.
On 23 June, he moved accommodation to be nearer work and more independent. He was
taking his medication. He felt he had control of his life.
On 7 July, he had stopped taking his antidepressants and reduced his quetiapine but his
lithium levels were stable. He was looking for a girlfriend.
On 21 July, he was content and rational. Dr Moran began to consider discharge from his
Community Treatment Order.
On 2 August, Dr Xu referred Mr Crivera back to Dr Hershel Goldman at Hampton Park Medical Centre. In his referral note, Dr Xu noted that he had ceased his Zoloft (sertraline)
himself and was currently stable.
On 4 August, he was still working full time and was still concerned about his sex drive. Dr Moran referred him to a sexual health clinic and decreased Mr Crivera’s zuclopenthixol from 125mg to 75mg because he was taking his mood stabiliser, quetiapine, and his mental
state seemed stable.
On 24 August, in the absence of Dr Moran, Dr Neerim Gill assessed Mr Crivera and began to consider cessation of his depot injections and discharge from the Community Treatment Order, On 25 August, he underwent a number of blood tests which indicated that he was
complying with his oral medication regime.
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13,
On 15 September 2006, Mr Crivera reported that he was happy with his current regime but
he would like to stop his injections because of erectile issues.
On 26 September, Mr Crivera‘s prolactin levels were low and his lithium and sodium
valproate levels were adequate. He was still working full time.
Dr Xu accepted that Mr Crivera‘s low prolactin levels could be a side effect of his zuclopenthixol. He decreased his zuclopenthixol dose further to 50mg. This is less than half the dose he was administered until 4 August. This new zuclopenthixol dose
commenced on 13 October 2006.
Then, on 13 October 2006, Mr Crivera told Ms Cook that he had suicidal thoughts but no plan. He remained pre-ooccupied with sexual function issues but there was a delay in obtaining an appointment from a specialist urologist. He said he was compliant with his
medication. He was bored at work. His land lady was hassling him.
Ms Cook was concerned’ about Mr Crivera’s mental state so she organised for him to be
reviewed immediately by Dr Xu.
Mr Crivera also told Dr Xu that felt low occasionally with suicidal thoughts but denied any intention to carry it out. He acknowledged he had become withdrawn and did not fit in because people thought he was weird. However, he refused an antidepressant and required
persuasion to accept an appointment with Dr Moran.
On 20 October 2006, Dr Moran assessed Mr Crivera’s mood as 1-2/10; his motivation had decreased; he had very negative thoughts, suicidal thoughts and anxiety; he was convinced his problems were due to social rather than psychiatric illness. Dr Moran diagnosed Mr Crivera
in a depressed phase of his bipolar illness.
Mr Crivera agreed to restart taking sertraline (Zoloft) and diazepam as required for anxiety.
Hawkes Pharmacy dispensed the sertraline on 20 October 2006 with advice to take one tablet
or 100mg each morning.
Afterwards, Ms Cook also rang Mr Crivera’s father but Mr Crivera was already at his place
having a sleep.
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On 24 October 2006, Mr Crivera’s mental state had not improved. He reported quitting work
and said his mood remained low but there was some improvement in his anxiety.
On 25 October, Mr Crivera accepted his second injection of 50mg zuclopenthixol. Dr Xu also reviewed Mr Crivera. He was too shy to approach Centrelink for unemployment funding. He was worried that he would not be able to have an implant. He had no thoughts of self harm and promised not to overdose on diazepam. He was going to Echuca for a few weeks. Dr Xu
prescribed more diazepam. This prescription was filled on the same day.
On 10 November 2006, Dr Xu reviewed Mr Crivera. His mood was better. However, the urologist could not exclude alternative explanations or agree to an implant until alternative
pharmaceutical management of the issue had been attempted.
On 14 and 20 November 2006, Mr Crivera failed to keep appointments for his depot injections. His father explained that they had been together for the last week and was
planning to return home on 24 November.
On 24 November 2006, Dr Moran assessed Mr Crivera after Mr Crivera’s father contacted her © express his concerns. Mr Crivéra admitted occasional thoughts of suicide but denied a plan. He denied non-compliance with his medication. He accepted his depot injection of 50mg zuclopenthixo! and his daily sertraline was increased to 250mg. This was dispensed on 28
November.
On 28 November 2006, Dr Moran reviewed Mr Crivera again. His mood remained 3/10. He had low motivation and energy and was unable to work. He slept excessively. He had low
self esteem but no current plan or intent to self harm.
Dr Moran advised Mr Crivera to increase his sertraline to 300mg if his mood did not improve
over the weekend. She was concerned about his mental state and she made arrangements for
Mr Crivera to spend another weekend with his father. He was referred for blood tests to check
his compliance with his medication and further review on 4 December 2006.
Mr Crivera failed to have the blood tests to confirm he was complying with his medication
before he went to stay with his father. On 2 December 2006, he returned to Ferntree Gully.
On 2 December 2006, Hawkes Pharmacy dispensed 60 tablets of quetiapine, 200 tablets of
lithium and 200 tablets of sodium valproate. All this medication had been prescribed for Mr
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24,
Crivera by Dr Xu on 27 June 2006. On the same day, Mr Crivera was last seen by Ms
Pandelias’ son.
At 2.00pm on 3 December 2006, Ms Pandelias found Mr Crivera unresponsive in his
bedroom. He was unable to be revived. Police found packaging for and unused tablets of
lithium, sodium valproate, quetiapine, sertraline and diazepam in Mr Crivera’s bedroom.
Combining the information available from the police brief and the PBS records I have
calculated that these drugs included:
Two unopened boxes of 100 x 450mg tablets of Quilonum (lithium) prescribed by Dr
_ Xuand dispensed on 30 August 2006 with advice to take 2 % tablets each night;
Two unopened boxes of 100 tablets of Quilonum (lithium) prescribed by Dr Xu and dispensed on 2 December 2006 with advice to take 2 % tablets each night;
Two opened boxes of 100 tablets of Quilonum (lithium) prescribed by Dr Xu and dispensed on 30 June 2006 containing 18 empty blister packs with advice to take 2 4% tablets each night;
Two unopened boxes of 100 x 500mg tablets of Valpro 500 (sodium valproate) prescribed by Dr Xu and dispensed on 30 August 2006 with advice to take three tablets at night
Two unopened boxes of 100 tablets of Valpro 500 (sodium valproate) prescribed by Dr Xu and dispensed on 2 December 2006
Two opened boxes of 100 tablets of Valpro 500 (sodium valproate) prescribed by Dr Xu and dispensed on 30 June 2006 containing 20 empty blister packs
One opened box of Valpro 500 (sodium valproate) prescribed by Dr K Yeang and dispensed on 5 February 2006 with two opened blister packs containing 12 tablets.
One opened box of 60 x 150mg tablets of Seroquel (quetiapine) prescribed by Dr Moran and dispensed on 5 April 2006 containing 26 tablets
One opened box of 60 tablets of Seroquel (quetiapine) prescribed by Dr Xu and dispensed on 30 June 2006 which was empty
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25,
26,
27,
. One opened box of 60 tablets of Seroquel (quetiapine) prescribed by Dr Xu and dispensed on 30 August 2006 which was empty
e One opened box of 60 tablets of Seroquel (quetiapine) prescribed by Dr Xu and dispensed on 2 December 2006 containing three unopened blister packs and 13 used or
empty blister packs
. One opened box of 30 x 50 mg tablets Xydep (sertraline) prescribed by Dr Xu and dispensed on 10 November 2006 with all tablets still in the box and advice to take one
tablet in the morning;
. One empty box of 30 tablets Xydep (sertraline) and one box with 15 tablets left still in the box prescribed by Dr Xu and dispensed on 28 November 2006 with advice to take 2
¥ tablets in the morning.
e One half full (about 100 x 250mg tablets left) bottle of Lithicard (lithium) prescribed by Dr Yeang and dispensed on 26 May 2006.
« Two empty blister packs for 20 tablets of Valpam (diazepam),
Post mortem toxicological analysis detected quetiapine (12mg/L), sertraline (1.7mg/L) and
mirtazepine (0.lmg/L). Zuclopenthixol is not usually detected.
The forensic pathologist, Dr Noel Woodford, who performed the autopsy formed the opinion that the cause of death was quetiapine toxicity in a man also consuming sertraline and
mirtazepine.
Dr Woodford is of the view that the post mortem concentrations of quetiapine and sertraline are at potentially excessive levels. In his opinion, the quetiapine was present at markedly excessive levels and is a drug known to cause significant hypotension and central nervous system depression in overdose. Typically serotonin re-uptake inhibitor-type-antidepressants are safer in overdose. Therefore he considered the quetiapine to be the major operative factor in terms of drug toxicity. He included the other drugs in the cause of death because of their potential additive affect with respect to central nervous system depression and the possibility
that other factors such as serotonin syndrome may have been an operative factor.
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sertraline are likely to have caused the death.
quetiapine toxicity in a man also consuming sertraline and mirtazapine.
Pursuant to section 67(3) of the Coroners Act 2008, I make the following comment(s) connected with the death:
11 Wynette Avenue in Upper Ferntree Gully.
not disclose any abnormality in cardiac function.
consuming sertraline and mirtazapine.
His case manager was Seigrid Cooke.
the mental illness in a manner less restrictive of his or her freedom of decision.
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10,
li.
The chief psychiatrist authorises consultant psychiatrists in approved mental health services in Victoria to take responsibility for ensuring that mental health patients are not subject to involuntary treatment orders if they do not meet the criteria established by the Mental Health
Act 1986.
In practice, this means that an authorised consultant psychiatrist must regularly review each involuntary mental health patient. Further, patients who understand the implications of their mental illness, accept treatment voluntarily, comply with the regime advised by their treating team and are not an immediate risk to themselves or other people in the community cannot
continue to remain on involuntary treatment orders.
Between June and the beginning of October 2006, Mr Crivera reported stopping his antidepressants himself and he had difficulty keeping his medical appointments because of his full time work. Mr Crivera was pre-occupied with an erectile difficulty which was a long-
standing condition but he attributed it to his zuclopenthixol.
However, in this context, Mr Crivera seemed to be managing his mental illness quite well during this time: He expressed insight into the need to maintain his medication regime.
Blood tests confirmed he was complying with his oral medication doses. His mental state was very stable. He was attending Chandler House regularly and reliably. He had moved into
new accommodation.
Accordingly, in August 2006, Mr Crivera’s treating team reduced his zuclopenthixol dose from 125mg to 75mg every two weeks, referred him to a urologist and began to plan for
discharge from his Community Treatment Order.
On 26 September 2006, his lithium and sodium valproate levels were adequate. He was still
working full time.
However, Mr Crivera’s mental state deteriorated over the following three weeks.
On 13 October 2006, Mr Crivera admitted to Ms Cooke that he had suicidal thoughts but no plan. He said he was still complying with his medication but he was unhappy with his work
and his impotence, Ms Cook was concerned about his decline.
Despite this deterioration in mental state documented on 13 October 2006, Dr Xu continued
with the plan to reduce Mr Crivera‘s fortnightly zuclopenthixol dose to 50mg.
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Although Mr Crivera continued to comply with the requirement that he present for his depot zuclopenthixol injections, his mental state continued to deteriorate throughout October and November 2006. In particular, Mr Crivera’s medical assessments confirmed relapse of the depressive phase of his bipolar illness against a background of continuing pre-occupation
about his erectile dysfunction.
Retrospective analysis of medication found after his death suggests to me that the deterioration in Mr Crivera’s mental state observed by his treating team in October and November 2006 coincided with reduction in his zuclopenthixol dose to 75mg and then 50mg every two weeks and his non-compliance with the lithium and sodium valproate doses
prescribed by his treating team from about 20 September 2006.
In particular, medication found in Mr Crivera’s room after he died included two empty boxes for 100 tablets of lithium dispensed on 30 June 2006 and two unopened boxes of lithium dispensed on 30 August 2006. The prescribed dose would require Mr Crivera to use about 75 tablets a month and he would use about 200 tablets between 30 June and 20 September 2006.
Of course, this end date would be extended by any period of partial compliance.
Similarly, there were two used boxes for 100 tablets of sodium valproate and two blister packs with 12 tablets of sodium valproate left dispensed on 30 June 2006 as well as two unopened boxes of sodium valproate both dispensed on 30 August 2006. The prescribed dose would require Mr Crivera to use about 90 tablets a month and he would use about 240 tablets between 30 June and 20 September 2006. This end date would also be extended by any
period of partial compliance.
However, Mr Crivera’s treating team did not actively respond to this coincidence in reduction in Mr Crivera’s zuclopenthixol dose, non-compliance with his prescribed oral medication and deterioration in his mental state because he denied the non-compliance and Dr Moran and Ms Cooke believed that he was frank with them about his use of medication. Dr Moran told the
Court:
“.. at the time I was completely convinced that he was compliant with medication because he told me, looking me straight in the eye on three or four occasions that he absolutely was and I believed him and I think the rest of the team believed him. He... appeared to be quite credible
in that respect.”
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21,
27,
Blood tests for lithium and sodium valproate taken in October 2006 would have shown that Mr Crivera was not taking his prescribed doses of lithium or sodium valproate. 1 have no doubt that this knowledge would have initiated an active response to his treating team’s
increasing concerms about his deterioration following his assessments on 13 and 20 October.
The clinical response to Mr Crivera’s continuing relapse also seems to have clouded by his pre-occupation with sexual dysfunction and the treating team’s accepting the possibility that
there was a relationship between his zuclopenthixol and his impotence.
Accordingly, no attempt was made to restore Mr Crivera‘s higher pre-August zuclopenthixol dose or order blood tests to provide collateral confirmation that he was complying with his oral medication regime. Rather, Dr Moran and Dr Xu introduced diazepam and restored
increasing doses of sertraline.
Further, Mr Crivera filled sertraline prescriptions on 20 October and 10 November 2006.
There was no evidence in his room of any sertraline remaining from the medication dispensed on 20 October but there was one unused package of sertraline dispensed on 10 November
Therefore, Mr Crivera seems to have either taken the dose of sertraline prescribed by Dr Xu on 20 October until about 20 November 2006 and then stopped taking it or he missed his doses on eight days during the period to 28 November 2006.
Accordingly, I find that treating team was idealistic in accepting his self-reported compliance with his oral medication despite well documented continuing deterioration in and concern about his mental state in October and November 2006, recent history of reducing his medication without consultation and a long-term history of sexual dysfunction which he
attributed to the more recent introduction of zuclopenthixol.
Further, blood tests ordered on 28 November 2006 also relied on Mr Crivera arranging for the blood to be taken and, even if they had occurred then, would probably have provided
information too late to reverse his decline.
I have no doubt that collateral evidence of Mr Crivera’s non-compliance with oral medication
and holistic analysis of his circumstances would have changed the way in which his treating
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team managed his deteriorating mental illness and increased his capacity to re-stabilise.
Recommendations 1,2 & 3
blood taken for testing before he went to stay with his father over the weekend.
November and three times the dose advised by Dr Moran if he had not improved.
collateral evidence before me that Mr Crivera committed suicide.
taking extra sertraline in a late attempt to reduce the effect of his mental illness.
Pursuant to section 72(2) of the Coroners Act 2008, I make the following recommendation(s)
connected with the death:
unexplained or continuing deterioration in their mental state.
otherwise unexplained or continuing deterioration in their mental state.
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patients’ mental state.
I direct that a copy of this finding be provided to the following: Minister for Mental Health
Chief Psychiatrist
Director of Psychiatry, Eastern Health
President, Royal-Australian and New Zealand College of Psychiatrists
Signature:
[oe
DR JANE HENDTLASS CORONER Date: 5 September 2013
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