Deceased
Anna Lawrence
Demographics
64y, female
Coroner
Coroner Audrey Jamieson
Date of death
2020-04-30
Finding date
2023-02-22
Cause of death
Combined toxicity to alcohol and baclofen
AI-generated summary
Anna Lawrence, 64, died from combined toxicity of alcohol and baclofen on 30 April 2020. She had a 40+ year history of alcohol dependency, borderline personality disorder, depression, and multiple suicide attempts. Baclofen was prescribed off-label for alcohol craving management by her psychiatrist in January 2019 but not redeemed until August 2019—approximately 1.5 years before her death. The coroner found no evidence that any clinician's conduct contributed to her death. However, the finding highlights systemic issues: baclofen lacks TGA approval for alcohol use disorder despite widespread off-label prescribing in Australia, creating an unregulated prescribing environment dependent on individual clinician judgment. The coroner recommends TGA consider approving baclofen for alcohol use disorder to establish safer prescribing guidelines, controlled dispensing protocols, and clearer contraindications for high-risk patients with mental illness or suicide history.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2020 002323 OF VICTORIA AT MELBOURNE FINDING INTO DEATH WITHOUT INQUEST Form 38 Rule 63(2) Section 67 of the Coroners Act 2008 Findings of: Coroner Audrey Jamieson Deceased: Anna Lawrence Date of birth: 28 February 1956 Date of death: On or about 30 April 2020 Cause of death: 1(a) COMBINED TOXICITY TO ALCOHOL
AND BACLOFEN Place of death: 17 Connor Street, East Geelong, Victoria, 3219 Keywords: Alcohol and Baclofen Toxicity, prescription drugs, intentional death, Therapeutic Goods Administration, Recommendation.
On 30 April 2020, Anna Lawrence (Anna) was 64 years old when she was found, deceased, in her home. At the time of her death Ms Lawrence was separated from her husband, Jeffrey Lawrence (Jeff), and lived in a unit in Geelong by herself.
Anna had three adult sons – ‘Ben, Tom and Sam’ who were borne of her first marriage.1 Background and formative years
Anna was born in the United Kingdom (UK)2 on 28 February 1956. She had an older sister, Jenny Davies (Jenny), and a younger sister, Lisa Westlake (Lisa). As a young child, Anna immigrated to Australia with her family, settling in Glen Iris, Melbourne where she and her siblings grew up.
According to Jenny, they did not have a happy childhood particularly after their parents’ relationship deteriorated. Around the same time, when Anna was ‘in her teen years’, she became “difficult” which coincided with their parents becoming ‘more and more unhappy with each other’. The evidence indicates that Anna’s teenage years were particularly challenging.3
Anna overcame her challenges, however, and qualified as a kindergarten teacher initially, before becoming a businesswoman. Jenny described her sister as a ‘beautiful woman’ who was jovial by nature.
Early adulthood
i. Anna had been married to her first husband, Mark Donald, for approximately 38 years.
ii. The evidence indicates that the marriage subsisted until approximately ‘the early 1990s’.
iii. Except for one reference to her youngest son’s full first name by Anna’s Clinical Psychologist, Ms Amy Joyce, only the diminutive variations of Anna’s sons’ names appear throughout the CB.
2 United Kingdom of Great Britain and Northern Ireland. The family’s exact origins in the UK are unclear.
3 CB, statement of Jenny Davies.
one of the properties, converting it into a ‘restaurant or kiosk’. The evidence indicates that they operated this business for a few years and then sold it.4
During the mid-1990s, Anna and Mark’s marriage ended. Shortly afterwards, Anna met Jeff who became her partner and, in 2007, they were married. According to Lisa, while her sister was married to Jeff, she ‘ran a successful gift shop’. However, in 2010, Anna was forced to sell the business ‘due to her declining health’.5 Anna’s health concerns
Around the same time that Lisa noticed that Anna’s health had begun to decline, she also noticed that her sister was consuming more alcohol and when Anna had ‘expressed extreme despair about her life’ and ‘[self-]esteem’, Lisa and Jenny advised their sister to seek ‘professional support’.6
Jenny, on the other hand, noticed that when Anna was drinking, ‘the behaviour it brought on’, as she became ‘incredibly drunk’, manifested ‘at times, [in] self harming’. (sic) According to Jenny, this was when she and Lisa ‘became worried’ about their sister who was, by then, ‘drinking throughout the day, every day’.7 (sic). Taking her sisters’ advice, Anna sought professional therapy to manage her mental health concerns and her addiction to alcohol. Her doctors prescribed a course of medication to manage her health concerns. The evidence indicates that her therapy was ongoing.
Despite her therapy sessions and her medication regime, however, Anna’s mental health continued to deteriorate, and it appears that her alcohol dependency issues became worse overtime. According to Jenny, from ‘about 2010’ onwards, Anna ‘started to really spiral down’ and was ‘admitted into various clinics’ (sic) on several occasions to manage her symptoms.8
After she was assessed during her admissions ‘into various clinics’, Anna was diagnosed with Behavioural Personality Disorder which, according to Jenny, manifested in her becoming 4 CB, statement of Lisa Westlake.
5 Ibid. Lisa described Anna and Mark’s ‘separation and divorce’ as ‘challenging’.
6 Ibid.
7 CB, statement of Jenny Davies. After Anna started therapy at a ‘women’s clinic’ on Jenny and Lisa’s advice, she continued consulting ‘a doctor’ at that clinic over the next 10-15 years, until the time of her death. The name of the clinic Jenny referred to in her statement is unclear, but Anna came to Melbourne for that treatment while living in Geelong.
8 Ibid. The evidence indicates that Anna’s admissions to clinics were so frequent that Jenny ‘lost count of the number of times’ that she had been admitted to mental health facilities to manage her alcohol dependency issues.
‘more and more disengaged’ from her loved ones. Anna was also treated for her alcohol addiction issues. When Jenny attended one of the ‘family information nights’ at one of the clinics Anna was admitted to, she learned that Anna’s detachment from her family was ‘typical of her diagnosis’.9
Jenny related that Anna’s life with Jeff ‘was initially very exciting’ but from about 2010 onwards, as her mental health began to decline, aggravated by her excessive alcohol consumption, Jenny noticed that Anna ‘started to seem unsettled by Jeff’. According to Jenny, Anna ‘used to check his phone and doubt him’ which they, as a family, ‘thought was unreasonable’.10
Over the next few years, Anna and Jeff’s ‘relationship continued to decline’ until ‘about October 2018’, when Anna ‘couldn’t cope any more’ (sic) and engaged a lawyer to serve ‘separation papers on Jeff’.11 The breakdown of Anna’s marriage to Jeff
According to Jeff, his wife’s ‘significant alcohol abuse’ started ‘in 2008’ and coincided with the onset of her mental health concerns and during 2009, she was diagnosed with Borderline Personality Disorder (BPD). Although Anna had told Jeff that her alcohol dependency issues ‘dated back’ to her ‘teenage years’, Jeff only noticed the severity of her addiction when Anna’s alcohol dependency advanced to a ‘downhill’ trajectory after her 50th birthday.12
Jeff related that his wife did not accept her BPD diagnosis and he believed that she ‘doctor shopped’ because of her ‘non acceptance of the BPD’. After Anna sold her business in 2010, she ‘rarely worked’ and Jeff believed that this was ‘due to her health’.13
Over the next 13 years or so, Anna had ‘40+ periods of rehabilitation time’ which varied in duration between one week and three months. During this period Anna attempted to commit suicide at ‘least 5’ times since her first suicide attempt by ‘Drug overdose’ (sic) in 2012.
Amidst growing concerns about Anna’s declining mental health and her alcohol dependency issues, Jeff questioned Anna’s access to prescription medication, given her condition and her 9 Ibid. Both Jenny and Lisa attended a few family information sessions with Anna. According to Jenny, Jeff and Anna’s sons also attended ‘a few’ of the sessions when Anna was first admitted into rehabilitation clinics.
10 Ibid.
11 Ibid.
12 CB, statement of Jeffery Lawrence.
13 Ibid. It is not clear whether Anna ‘doctor shopped’ for a second opinion on her BPD diagnosis or whether the reference relates to prescription medication “doctor shopping”.
diagnosis. According to Jeff, he was ‘concerned about how someone with her condition’ could so readily access ‘so many benzodiazepines’ and when she took Valium it was ‘impossible to converse’ with Anna ‘in any rational way’ whether it was ‘combined with alcohol or not’.14
In July 2015, Anna’s vehicle was fitted with an ‘interlock device’ after Anna had a number of ‘drink driving episodes’. Even after her vehicle was fitted with the interlocking device, Anna did not desist from driving her vehicle while under the influence of alcohol. According to Jeff, Anna was known to stop at a liquor outlet on her way home from her consultations with her doctor, leave the engine to idle, consume the alcohol and continue driving. On one occasion, she was denied access to a rehabilitation centre where she was an inpatient on her return from a ‘special leave day’, when she stopped for a drink on her way back and the facility officers detected that she had consumed alcohol.
In 2018, without her family’s knowledge and without authorisation, Anna had the interlock device disconnected and embarked on a long-distance journey. On this journey, near Euroa in country Victoria, Anna was involved in a single vehicle incident which caused irreparable damage to her vehicle. The ensuing investigation revealed that Anna was under the influence of alcohol when the incident occurred and, consequently, her driving licence was suspended.
Around the same time, Anna was also involved in at least three incidents of theft which attracted the attention of Victoria Police.15 During this time, Anna had also defaulted on her Alcoholics Anonymous (AA) sessions, which she had been attending ‘Off & on’ since 2015.
Jeff also noticed, after her many AA sessions and her numerous admissions to rehabilitation clinics, that Anna ‘tended to associate’ with her ‘AA friends’ and her ‘fellow Rehab patients’ and ‘specifically’ dissociated herself from her own friends and family. According to Jeff, Anna believed that her acquaintances from AA and the rehabilitation facilities she attended, ‘understood her better’.16
15 Court File, Law Enforcement Assistance Program (LEAP) record. Anna was convicted of theft in the circumstances of shoplifting on the following dates: i. 14 July 2017; ii. 17 January 2018; and iii. 13 July 2018.
16 CB, statement of Jeffery Lawrence.
her ‘relationship and future’ with Jeff in the last ‘18-24 months’ before her death, but he ‘always put it off’ until later.17
During one of Anna’s stints in a rehabilitation centre, sometime during 2018, ‘Jeff and Sam’ organised ‘a unit’ for her to move into pending her discharge from the facility so that when she was eventually discharged, she could move into the unit. The evidence indicates that this unit is where Anna was living at the time of her death.18
From October 2018 onwards, during the last ‘18 months’ of her life, Anna’s mental health was in sharp decline, and she spent more time in rehabilitation clinics as an inpatient than as an outpatient. During one of her inpatient stints, Anna befriended Peter Tregent (Peter), a fellow patient. Anna found support and ‘solace’ with Peter and often stayed with him when they were not booked into the rehabilitation centre. Sometime later, Peter became Anna’s partner.19 Anna’s most recent “suicide attempts”
According to Peter, when he and Anna befriended each other approximately three years prior to her death, she confided in him and told him about her previous attempts to commit ‘suicide on several occasions’. Approximately ‘6 months’ after they had met, they ‘formed a relationship’ and spent much time together at his farm in Strathbogie in country Victoria.
Their relationship subsisted for ‘2 and a half years’ until approximately two weeks before Anna’s death.20
According to Jenny, the move happened ‘some months’ before Anna caused separation papers to be served upon Jeff which, she says, occurred around ‘October 2018’.
19 CB, statement of Clinical Psychologist, Amy Joyce.
20 CB, i. statement of Peter Tregent ii. statement of Lisa Westlake, according to whom Anna and Peter ‘split up mid April’.
the mediation process as ‘lengthy’ as ‘Jeff would avoid/delay replying to correspondence regarding settlement’.
In addition to Anna’s marital issues, she appeared to have been adversely affected by the ‘deterioration of her relationship’ with her sons, one of whom continued to live with Jeff despite the breakdown of his mother’s marriage to Jeff. Peter believed that Anna’s separation from her family, particularly her sons and her grandchildren, contributed to her ‘poor mental health’ at the time.
In June 2019, while Anna and Peter were staying at Peter’s mother’s house in Camberwell, Anna attempted to commit suicide ‘by overdosing on prescription medication’. After emergency services were called, Anna was admitted to the Intensive Care Unit at Box Hill Hospital (BHH).
Medical management of Anna’s health concerns
Dr Thuy Nguyen of the Church Street Medical Centre (CSMS) in Richmond, was Anna’s doctor (GP) for the ‘last 10-12 years’ prior to her death. According to Dr Nguyen, Anna had a ‘problem with alcohol dependency for longer than’ he had ‘known her’ and her chronic depression and anxiety was associated with ‘her alcohol [addiction]’.21
Anna’s medical records held on file at the CSMS reflected that she had been treated for her mental health concerns for ‘many years’ by mental health professionals which included more than one medical specialist. In addition, during the time that Anna had been Dr Nguyen’s patient, she had been admitted to the Beleura Private Hospital (BPH) on ‘several’ occasions for inpatient treatment to manage her alcohol dependency issues and while Anna remained a BPH outpatient, she was ‘under the care of Dr Michael O’Ryan.22
Dr Nguyen noted further that, in recent times, Anna had ‘struggled with ‘her marital break up’ (sic) and ‘was in the process of property settlement just before she passed away’.23
In November 2018, Dr Nguyen made the following diagnoses, amongst others:24 i. Duodenal ulcer; 21 CB, statement of Dr Nguyen, 22 Ibid. According to Dr Nguyen, Anna was under the care of Specialist Psychiatrists, Drs Samari Jayarajah and Sinnatamby Sujeevan and Psychologist, Ms Amy Joyce.
23 Ibid. Dr Nguyen noted further that Anna’s personal relationships with her family ‘had been challenging’ for her ‘because they did not approve of her drinking’. However, she enjoyed the support of her sister.
24 Ibid. I have omitted those medical conditions which are not relevant to my Finding.
ii. Migraine; iii. Alcohol abuse; iv. Chronic depression and anxiety-related symptoms; v. Borderline Personality [Disorder].
Dr Nguyen prescribed the following medicines to manage Anna’s conditions:25 i. Inderal;26 ii. Lamictal;27 iii. Lexapro;28 iv. Naltrexone;29 v. Nexium;30 vi. Temaze;31 vii. Thiamine;32 viii. Valium.33 Specialist management of Anna’s mental health concerns
Dr Sinnatamby Sujeevan of The Melbourne Clinic (TMC) in Richmond was Anna’s Consultant Psychiatrist since March 2017. Initially, Anna was a patient of Dr Samari Jayarajah at the same clinic but came under Dr Sujeevan’s care when Dr Jayarajah had ‘taken a leave of absence’. The evidence indicates that Anna had been a patient at TMC for an extended period prior to her death.34
Sometime in the period that Anna was Dr Sujeevan’s patient, she had admitted to having ‘suicidal thoughts in August 2017 and in October 2017’. Dr Sujeevan noted further that, at 25 Ibid. The medication was in tablet form, both chewable and otherwise. I have omitted those medicines which are not relevant to my Finding.
26 Indicated for the treatment of hypertension (high blood pressure).
27 Lamotrigine, marketed under the brand name Lamictal, is indicated for the treatment of Bipolar Mood Disorder and to prevent or control seizures.
28 Indicated for the treatment of depression and anxiety.
29 An opioid antagonist drug, indicated for the treatment of alcohol dependency, amongst other things.
30 Antacid medication.
31 Temazepam is indicated for the treatment of insomnia 32 Vitamin B1, indicated where this micronutrient is deficient.
33 Indicated for the treatment of anxiety-related disorders, alcohol withdrawal symptoms and seizures, amongst other things.
34 CB, statement of Dr Sinnatamby Sujeevan
her last consultation at TMC, on 17 December 2019, Anna mentioned her June 2019 admission to BHH after she ‘took one overdose of (. . .) Baclofen along with alcohol’.35
During that last consultation, Dr Sujeevan also noted that Anna was feeling ‘somewhat unsettled and chaotic’ but appeared to be dealing with her mental health-related issues relatively well. According to Dr Sujeevan, Anna had discussed her plans to leave the Geelong area and move to greater Melbourne before eventually relocating to New South Wales.
With regard to Anna’s alcohol dependency issues, Dr Sujeevan noted that her ‘alcohol consumption had fluctuated’ but that she ‘had admitted’ to him ‘that she had not always been candid about the amount she drank’. However, when she felt ‘vulnerable’ or ‘during times of distress’, Anna arranged for herself to be admitted to the BPH Alcohol Rehabilitation Unit or contacted ‘friends’ who provided ‘support’.
Accordingly, after her last consultation at TMC on 17 December 2019, Dr Sujeevan was confident that ‘there was no evidence of deterioration’ in Anna’s ‘depression or of her having any suicidal ideation’.36 Psychology counselling37
While Anna was undergoing treatment by her GP and her Psychiatrist, she was also supported by Clinical Psychologist, Amy Joyce of Focused Psychology Clinical Psychology Services.
This practice had consulting rooms in Melbourne and in Geelong.
According to Ms Joyce, Anna had been her patient since December 2017 on referral by her GP.
During Anna’s consultations with Ms Joyce, it had come to light that the genesis of Anna’s mental health concerns and alcohol dependency issues, was her own parental home. Ms Joyce noted that Anna’s ‘difficult childhood’ stemmed from her father’s alcoholism and his tendency towards family violence, both physically and emotionally. Anna reported that although she ‘idealised’ (sic) her father who was ‘a high-profile thoracic surgeon’, it was he who ‘taught her to drink at a young age’. In addition to her father’s ‘violent alcoholic’ ways, 35 Ibid.
36 Ibid.
37 CB, statement of Amy Joyce, Clinical Psychologist.
by Anna’s perception, her mother ‘favoured her siblings’ over her and ‘she felt [that she was] the “black sheep” of the family’.38
Anna reported further that both her marriages broke down in similar circumstances to the family life she experienced in her parental home. Although she maintained contact with some family members, she was estranged from others who appeared to be allied to her husband, Jeff. The evidence indicates that Anna believed that her relationship with her own family had become ‘strained over the years due to her bouts of alcoholism’.
In addition to her ‘long history of alcoholism’, Anna presented to Ms Joyce with ‘a long history of dysregulated affect, and bouts of depression’. According to Ms Joyce, she was aware of Anna’s numerous admissions ‘to psychiatric or addiction treatment centres’ after she had ‘attempted to take her life many times’. Ms Joyce was also aware that, in recent times, Anna had attempted to take her own life ‘on several occasions’ by ‘overdosing and drinking alcohol’.39
Ms Joyce diagnosed Anna with Borderline Personality Disorder (BPD) and Alcohol Use Disorder ‘on the background of a traumatic abusive childhood, and re victimisation in adult life in several relationships’. (sic)
Although Anna found ‘psychology’ as a discipline ‘particularly confronting’, having not consulted a psychologist before, despite her having ‘experienced a lifetime of dysfunctional relationships’, she ‘easily developed a solid rapport’ with Ms Joyce. Accordingly, to manage Anna’s symptoms, Ms Joyce devised a combined treatment plan (TP) which included the following:40 i. Mindfulness Based Cognitive Therapy; ii. Dialectical Behaviour Therapy; iii. Psychodynamic Therapy; and iv. Insight Orientated Therapy.
38 Ibid. In the context within which the statement is written, the word “idolised” would appear to be what the writer meant by the word “idealised”.
39 Ibid. Anna pointed out a tattoo on her wrist to Ms Joyce, which according to her, was to cover ‘an old scar of where she had attempted to take her life’.
40 Ibid, Ms Joyce described Anna as one with ‘self-loathing and [an] ambivalent attachment lifestyle]. The evidence indicates that while Anna was Ms Joyce’s patient, other that her contact sessions with her psychologist, Anna preferred to lead a solitary life.
Despite the TP being in place, Ms Joyce felt that Anna was only making ‘limited progress’ because her sessions were ‘infrequent’, with ‘gaps in treatment due to [her] admissions to addiction centres and unrelenting crises’. Ms Joyce catalogued Anna’s ‘unrelenting crises’ as follows: i. Anna’s separation ‘from her husband’ and her relapse ‘in alcoholism’; (sic) ii. Annas’s three-week admission to the Beleura Clinic for her alcohol dependency issues; iii. Anna’s divorce settlement negotiations with Jeff and the concomitant legal proceedings; iv. Anna’s relationship with Peter whose own drinking habits ‘led’ Anna to ‘joining in and relapsing’.
On 22 April 2020, Anna attended her last consultation with Ms Joyce. During the consultation, Anna appeared to be ‘slightly intoxicated and smelling of alcohol’. Ms Joyce noted that Anna’s divorce settlement mediation was unsuccessful, and she was consulting ‘her lawyer’ to plan her ‘next step in the process’. Anna also ‘admitted to drinking heavily again’ and she considered ‘admitting herself to an addiction centre’. Anna ‘denied any suicidal ideation’, however.
Anna’s admissions for substance abuse rehabilitation
From 2015 onwards Anna had multiple admissions to treatment facilities to manage her alcohol addiction and her mental health issues. Among these, Anna was admitted to the Wyndham Clinic Private Hospital (WCPH), Alcohol and Drug Unit in Werribee and the Beleura Private Hospital (BPH), Mental Health and Alcohol Addiction Unit (MHAAU) in Mornington.
Anna’s medical records at BPH indicated that between 2015 and 2017, she had nine ‘inpatient admissions’ and ‘55 day patient’ or outpatient attendances. Further, between 2018 and 2020, Anna had ‘4 inpatient admissions’ and ‘1 day patient admission’.41 41 CB, Letter from Monique Nicolaou, Nurse Unit Manager at BPH to DSC Narmoyle, Coroner’s Investigator dated 19 January 2021.
Similarly, Anna’s medical records at WCPH reflected that she had one inpatient admission from 26 June 2019 to 23 July 2019 and thereafter, she had eight outpatient sessions between 1 August 2019 and 5 December 2019.42 Anna’s treatment at BPH
Monique Nicolaou, Nurse Unit Manager (NUM) of the MHAAU at BPH provided insight, gleaned from the medical records, into Anna’s presentation at BPH, the diagnoses made and the treatment she received over the period that Anna was a BPH patient.
According to the NUM, Anna’s medical records reflected that she had ‘previous suicide attempts including an overdose in 2011 and June 2019’. However, during her ‘period of admission’ to BPH, Anna ‘denied any suicidal ideation’. The evidence indicates that the ‘period of admission’ referred to, is that period proximate to Anna’s death.
On her last admission to the MHAAU, 7 February 2020, Anna completed ‘a 28 day rehabilitation program’ during which was diagnosed with Alcohol Use Disorder and Borderline Personality Disorder and Recurrent Depression. Anna’s treatment program included a prescription for: i. Propranolol;43 ii. Escitalopram;44 iii. Lamotrigine;45 and iv. Naltrexone.46
Before Anna was discharged on 6 March 2020, she was reviewed by MHAAU clinicians at BPH, taking into account the Mental Health Risk Assessment record, documented upon her admission, ‘and deemed low imminent risk to self’. (sic)
Anna was advised to continue her follow-up consultations with her own psychiatrist at TMC and her psychologist, Ms Joyce, and was advised further that she may benefit from further treatment at TMC in the lead up ‘to her court case’ later that month.
42 CB, statement of Dr Anindya Banerjee 43 Indicated for the treatment of anxiety-related disorders.
44 Indicated for the treatment of depression and generalised anxiety disorder (GAD).
45 Marketed under the proprietary name Lamictal, the drug is indicated to treat epileptic seizures and as a mood stabiliser in patients diagnosed with Bipolar Mood Disorder (BMD).
46 Indicated for the treatment of alcohol use disorder and/or opioid use disorder.
Anna’s treatment at WCPH47
On 4 June 2019, Anna was admitted to BHH after she attempted to commit suicide by ‘intentional overdose’ on Baclofen tablets ‘in the context of heavy alcohol use’ while she was staying at Peter’s mother’s house in Camberwell. When her condition improved and she was deemed to be stable, she was transferred to the Swanston Centre in Geelong, on 13 June 2019, for further inpatient psychiatric treatment.
On 26 June 2019, Anna was discharged from the Swanston Centre but referred to the WCPH Alcohol and Drug Unit (Illira Unit) to continue her ‘inpatient rehabilitation program’ aimed at preventing a ‘relapse of alcohol use’. Accordingly, Anna was transferred to the WCPH Illira Unit where she was an inpatient for approximately one month, under the care of Consultant Psychiatrist, Dr Anindya Banerjee.
On admission to the Illira Unit, Dr Banerjee noted Anna’s ‘multiple suicidal attempts’ which were ‘often impulsive, and triggered by stressful life events’, marred by family violence and alcohol abuse which started when she was 18 years old. Dr Banerjee noted further that Anna had multiple admissions to ‘drug and alcohol units’ in ‘the last 10 years’ prior to her admission to the Illira Unit.
According to Dr Banerjee, her separation from Jeff and ‘the upcoming divorce proceedings were big stressors’ for Anna and ‘led to [the] exacerbation of [her] depression leading to the overdose’ for which she was admitted to the Illira Unit.48
Upon examining Anna, Dr Banerjee noted that her ‘mood’ was ‘anxious’ and although ‘she was help seeking’ (sic), she ‘denied any active thoughts of self harm or suicide’. Accordingly, Dr Banerjee focused on Anna’s ‘rehabilitation from alcohol’ and aimed to ‘stabilise her depressive symptoms’.
As Anna had already undergone her ‘detox’ program at BHH and at the Swanston Centre, Dr Banerjee proceeded to engage her in ‘group programs’ at the Illira Unit for the duration of her inpatient confinement. According to Dr Banerjee, Anna integrated into the program and in individual sessions well and her demeanour was ‘pleasant and polite’. The evidence indicates that Anna had made such good progress as an inpatient, that by the ‘second week of [her] 47 CB, statement of Dr Anindya Banerjee 48 Ibid. Anna also told Dr Banerjee that her estrangement from her youngest son was one of her stress factors.
admission’, she was allowed ‘accompanied leave’ from the Illira Unit to consult with her lawyers, amongst other things.
In addition to her group and individual sessions where Dr Banerjee discussed ‘strategies to manage her triggers for alcohol use’, Anna’s prescription medication was reviewed and, while some of her medication was continued, her sedative medication, ‘Diazepam and Temazepam were tapered and stopped’. After Anna had expressed her desire for ‘complete abstinence from alcohol’, Dr Banerjee discussed prescription options to assist her to abstain from alcohol. By informed consent, Anna elected to start a course of Disulfiram which Dr Banerjee then prescribed.49
Having observed Anna’s progress throughout the duration of her inpatient admission at the Illira Unit, Dr Banerjee felt confident that Anna ‘was improving in her mood’ and that she displayed an ‘ability in challenging her negative thinking’. Dr Banerjee was also satisfied that Anna’s liver function test results of 9 July 2019 ‘showed significant improvements compared to the test’ results of 16 June 2019. Consequently, Dr Banerjee took the view that Anna was ready to be discharged from the Illira Unit.
For a second opinion, Dr Banerjee referred Anna to Dr Raj Mahasuar, Director of the Drug and Alcohol Treatment Program at WCPH. Upon his review of Anna on 12 July 2019, Dr Mahasuar noted that she ‘was well engaged in the program and was motivated to complete the program’. Dr Banerjee then proceeded to discharge Anna from the Illira unit and devised a discharge plan with the focus on ‘crisis planning’ which included the following: i. Appointment with GP, Dr Nguyen at the CSMC on 31 July 2019; ii. Appointment with Psychiatrist, Dr Sujeevan at TMC on 31 July 2019; iii. Appointment with Clinical Psychologist, Amy Joyce in August 2019; and iv. Enrolment in the WCPH’s Alcohol and Other Drugs (AOD) Program, starting on 1 August 2019.
On 22 July 2019, Dr Banerjee reviewed Anna for the last time before her discharge from the Illira Unit. During this consultation, although Dr Banerjee found Anna to be ‘anxious about 49 Ibid.
i. Anna had a choice of three medicines to assist her in her plight to become fully abstinent from alcohol— Acamprosate, Disulfiram and Naltrexone. Dr Banerjee discussed each in turn, replete with the associated risks and side effects of each medicine when used in conjunction with alcohol.
ii. Disulfiram is indicated to support the treatment of chronic alcoholism. It works by mimicking the effects of a “hangover” to be felt immediately upon the consumption of alcohol.
[her imminent] discharge and [her] relationship issues’, by his assessment, Anna’s ‘anxiety was reality based and proportionate to [her] actual stressors’. According to Dr Banerjee, Anna did not have ‘psychotic symptoms’ or any ‘active suicidal ideas or intent’. The evidence indicates that Dr Banerjee was satisfied with Anna’s recovery and that due to her progress as an inpatient, she was well-placed to be discharged.
On 23 July 2019, Anna was discharged from the Illira Unit. Her medical records of that date indicate that Anna was diagnosed with Alcohol Use Disorder and Borderline Personality Disorder. Dr Banerjee noted that Anna ‘was not clinically depressed at the time of discharge from WCPH’ and her ‘immediate risks [of self-harm]’ were ‘low’. Dr Banerjee noted further, however, that Anna’s ‘medium to long term risk to self/suicidal risk was significant, given her personality vulnerabilities and her upcoming stressors (upcoming divorce [and] social isolation)’. In this regard, acknowledging that Anna had a ‘moderate risk of relapse of alcohol use given her long history of relapses, and ongoing stressors’ it was Dr Banerjee’s view that Anna’s ‘risk [of self-harm] would increase considerably if she relapsed on alcohol use’.
The evidence indicates that that Anna’s discharge plan devised by Dr Banerjee sought to minimise the risk and effects of any relapse to alcohol abuse and “suicidal ideation” that Anna may be confronted with.
Anna’s engagement in the AOD Program50
This day program, administered by WCPH, was tailored to Anna’s specific needs, and was designed to complement her ongoing sessions with her GP at CSMC, her Psychiatrist at TMC and her Clinical Psychologist, Ms Joyce.
The day program focused on building skills to maintain abstinence from alcohol and to provide support for Anna’s mental wellbeing. To this end, the topics of discussion included Anna’s ‘habits, [her] triggers, [her] support networks, [her] self-compassion and [her] distress tolerance’ and aimed to assist her in ‘reducing [her] vulnerabilities, [creating] decisional balance to manage urges, [promoting] mindfulness’ and further to assist her to manage ‘stages of change, anxiety and problem solving’.
According to Dr Banerjee, Anna’s attendance was ‘irregular, with frequent absences’.
However, when she attended her sessions, Anna ‘was noted to contribute well and utilise the group as a positive source of peer support’. Anna maintained that her ‘key stressors’ were ‘her 50 Ibid. Cf paragraph 34 supra.
marital separation’ and her ‘strained relationship’ with her son and that she still ‘experienced problems with depression, alcohol use and Borderline Personality traits’.
After her session on 5 December 2019 when she reported ‘ongoing low mood’, Anna’s attendance at the AOD became ‘erratic’ and the clinician had great difficulty in contacting her when she failed to attend her scheduled meetings on 12 December 2019 and 19 December
However, these attempts were in vain, and Anna was formally discharged from the AOD on 19 March 2020. Anna’s private treating team at the CSMC and TMC and her Clinical Psychologist, Ms Joyce were informed of the developments with regard to Anna’s AOD sessions and the circumstances under which she was discharged from the program.
Anna’s death was reported to the Coroner as it fell within the definition of a reportable death in the Coroners Act 2008 (the Act). Reportable deaths include deaths that are unexpected, unnatural or violent or result from accident or injury.
The role of a coroner is to independently investigate reportable deaths to establish, if possible, identity, medical cause of death, and surrounding circumstances. Surrounding circumstances are limited to events which are sufficiently proximate and causally related to the death. The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability.
Under the Act, coroners also have the important functions of helping to prevent deaths and promoting public health and safety and the administration of justice through the making of comments or recommendations in appropriate cases about any matter connected to the death under investigation.
Victoria Police assigned an officer to be the Coroner’s Investigator for the investigation of Anna’s death. The Coroner’s Investigator conducted inquiries on my behalf, including taking
statements from witnesses – such as family, the forensic pathologist, treating clinicians and investigating officers – and submitted a coronial brief of evidence.
MATTERS IN RELATION TO WHICH A FINDING MUST, IF POSSIBLE, BE MADE Circumstances in which the death occurred
On 7 April 2020, Anna attended a divorce mediation session with Jeff, accompanied by Lisa as her ‘support person’. According to Lisa, after the mediation session, the outcome of which was unsuccessful, she drove her sister back to Camberwell, to Peter’s mother’s home, where Anna was staying at the time. With the first COVID-19 Pandemic-related social-distancing restrictions in place at the time, that was the last time that Lisa saw her sister. They spoke to each other ‘most days’, however. Their conversations centred largely around Anna’s divorce settlement with Jeff and her ‘finances’.52
Taking Lisa’s advice, Anna approached Jeff to initiate divorce settlement negotiations so that they could avoid protracted court proceedings. According to Jeff, on 8 April 2020, he received a text message from Anna to which he did not respond because the parties’ respective lawyers were already engaged in settlement negotiations and their divorce matter was set down for hearing in February 2021.
Over the next two weeks or so, Anna continued to contact Jeff, by text message and voice message, urging him to meet with her to discuss their divorce settlement. Jeff responded to some of the messages indicating that he would be amenable to meet with her ‘Maybe later’ the following week so that they could ‘reach some consensus which can lead to a positive 51 Subject to the principles enunciated in Briginshaw v Briginshaw (1938) 60 CLR 336. The effect of this and similar authorities is that coroners should not make adverse findings against, or comments about, individuals unless the evidence provides a comfortable level of satisfaction as to those matters taking into account the consequences of such findings or comments.
52 CB, i. statement of Lisa Westlake.
ii. Statement of Jeffery Lawrence according to whom the meeting was conducted remotely and mediated by a ‘court appointed mediator’. The last time Jeff had seen Anna ‘personally’ (sic) was on 18 October 2019 when they attended to a matter unrelated to their divorce proceedings. The respective locations from where the parties joined the meeting electronically, is not clear from the evidence before me.
outcome for everyone concerned’. According to Jeff, by the tone of Anna’s voice message, it was ‘evident that she was under the effect of either alcohol or medication or both’.
On 29 April 2020, while at work, Jeff received a phone call from Anna which he did not answer at the time because it was inconvenient to do so. Shortly afterwards, Anna sent a text message to Jeff which he ‘knew’ was ‘a call for help’. When Jeff tried calling Anna, she did not answer her phone. Jeff immediately informed Lisa about the text message and that Anna was not responding to his calls.53
After several attempts between Jeff and Lisa to contact Anna were unsuccessful, at approximately 4.30 pm, Jeff took the decision to drive to Anna’s unit, arriving there at approximately 4.35 pm. After Anna failed to answer Jeff’s knock on her front door, he gained access to her unit via a side door which he found open, but he could not find Anna inside.
When Jeff then called out to Anna and she then responded, he found her sitting in the garage.
According to Jeff, it was ‘clear’ to him that ‘she was both medicated and under the influence of some alcohol, but she was extremely calm and rational in her responses’ to him.54
During their discussion, Jeff asked Anna what her text message meant and whether she ‘was planning to end her life or do something stupid’. Anna denied suicidal intent.
After spending about one and half hours with Anna, Jeff left her unit at approximately 5.50 pm. He then contacted Lisa to give her feedback about the events of the day and to discuss Anna’s financial concerns and her needs. While Jeff was talking to Lisa, he was still parked outside Anna’s unit and could see her ‘moving around her home’ because her blinds were not drawn. According to Jeff, after he left, ‘Lisa was going to do a follow up with Anna’.55
On 30 April 2020, when Lisa tried to phone her sister, Anna did not answer her calls. After several unsuccessful attempts during the course of that day, Lisa contacted the emergency services number ‘000’ and requested a ‘welfare visit because she was worried’.56 53 CB, statement of Jeffery Lawrence who was on a call ‘to a customer’ when Anna called his mobile phone. The text message was tantamount to a “suicide note”.
54 Ibid.
55 Ibid.
56 CB, statement of Lisa Westlake and statement of Coroner’s Investigator DSC Warren Normoyle.
i. The date is inferred from the context in which the statement is written and in the context of my investigation as a whole.
ii. According to Lisa, she called ‘000 around 12.45 pm’ after trying ‘many times’ to ‘call the Geelong Police station (. . .)’. However, Victoria Police received the ‘welfare check’ request at approximately 2 pm, arriving at Anna’s home at approximately 3.30 pm.
At approximately 3.30 pm, when Victoria Police arrived at Anna’s home, after their door knock was not answered, they gained access to her unit via the front door which was unlocked.57
The police discovered a person who they believed to be Anna Lawrence, ‘deceased lying on her right hand side on the kitchen floor’ with a ‘purple/blue’ complexion, ‘extremely cold’ and with a ‘small amount of dried blood’ coming from her nose.58
Ambulance Victoria (AV) paramedics attended the scene and pronounced the person, who was believed to be Anna Lawrence, deceased at 3.35 pm.59
Victoria Police investigations revealed various medicines and medication packaging and glasses which appeared to contain red wine and an unidentified substance with ‘a cloudy colour/layer’, next to which ‘was a bowl that contained approximately ‘15 (. . .) tablets’ and a ‘second small bowl’ containing ‘a powder residue’.60
Victoria Police discovered two documents which appeared to be “suicide notes” on the table in the dining room. Further investigations did not identify any signs of suspicious or criminal activity.
Identity of the deceased
Medical cause of death
In the execution of his duties, Dr Burke reviewed a post-mortem computed tomography (CT) iii. According to DSC Normoyle, when he arrived at the scene at approximately 3 .35 pm, first responders including AV paramedics were already there.
iv. In my view, the timeline provided by Victoria Police, corroborated by the evidence of the AV paramedics, appears to be a more accurate reflection of when the call for a ‘welfare check’ was made and responded to.
57 Court File, Police Report of Death, Form 83.
58 Ibid.
59 Court File, AV Verification of Death Form.
60 Ibid. Numerous prescriptions for medication were also discovered in the unit.
scan and the Police Report of Death, Form 83, and provided a written report of his findings dated 23 July 2020.61
Toxicological analysis of post-mortem samples identified the presence of:62 i. Ethanol 0.29 g/100 mL;63 ii. Ethanol 0.34 g/100 mL;64 iii. Baclofen ~ 5.5 mg/L;65 iv. Diazepam ~ 0.2 mg/L;66 v. Nordiazepam ~ 0.3 mg/L;67 vi. Citalopram ~ 0.1 mg/L;68 and vii. Lamotrigine ~3.8 mg/L;69
Forensic Toxicologist, Samantha Joubert of the VIFM commented that the ‘alcohol and baclofen is consistent with excessive use and ‘combination of the drugs detected may cause death in the absence of other contributing factors’.70
Ms Joubert commented further that a ‘blood alcohol concentration in excess of ~30% can cause death in the absence of other contributing factors’.71
Dr Burke opined that the medical cause of death was 1 (a) COMBINED TOXICITY TO ALCOHOL AND BACLOFEN.
63 Ethyl alcohol, used in the manufacture and production of alcoholic beverages. This concentration was detected in the sample of blood drawn from the deceased.
64 This concentration was detected in the vitreous humour of the deceased’s eye.
65 Baclofen is listed in a class of medications called skeletal muscle relaxants. It is indicated the treatment of musculoskeletal conditions caused by other medical conditions including, inter alia, Multiple Sclerosis (MS).
66 A benzodiazepine drug indicated for the treatment of anxiety and seizures.
67 A benzodiazepine derivative drug indicated for its sedative properties to treat anxiety.
68 An antidepressant drug.
69 An antiepileptic drug also indicated for the treatment of Bipolar Mood Disorder 70 Court File, Toxicology Report 71 Ibid.
including the preliminary examination and opinion of Dr Burke that a reasonable medical cause of death could be established as a medication overdose.72
Consequently, on 10 June 2020, to substantiate Dr Burke’s preliminary opinion, Detective Senior Constable (DSC) Normoyle, my Coroner’s Investigator, was directed to compile a directed brief of evidence to include the following, inter alia:73 i. Details of Anna’s background including her personal and social circumstances; ii. Details of Anna’s medical and mental health history and any history of her “suicidality”; iii. Anna’s history of illicit and/or prescription drug use; and iv. Anna’s history of alcohol use.
On the same day, at my Direction, Anna’s family was informed of the progress of my investigation into Anna’s death and of the proposed course my investigation would take, given Dr Burke’s preliminary opinion.74
On 16 June 2020, on behalf of the family, Lisa responded to the letter from the Court dated 10 June 2020 and expressed her concerns that her sister ‘had access to enough medication to [commit] suicide’, given Anna’s history of attempts to commit suicide and her history of extensive medical treatment to manage her mental health concerns and her alcohol dependency issues. According to Lisa, she was ‘hoping’ that this aspect of Anna’s death ‘will be investigated’.75
Given the preliminary opinion of Dr Burke, I was satisfied that Lisa’s concerns were connected to Anna’s death and required further investigation.
73 DSC Normoyle was directed to obtain statements from Anna’s family, friends and her medical treating team to advance my investigation.
74 Court File, Letter from the Court addressed to Jeffery Lawrence dated 10 June 2020.
75 Court File, email from Lisa Westlake to the Court.
Direction, in order to identify the prescriber(s), the Department of Health and Human Services (DHHS) was requested to provide me with the details of any permits to prescribe Schedule 8 drugs or poisons to Anna Lawrence.76
On the same day, the Acting Manager of the DHHS Safer Prescribing Team -- Medicines and Poisons Regulation, informed the Court that the DHHS did not hold any ‘record of Schedule 8 treatment permits’ for Anna Lawrence in their database.77
On 28 January 2021, DSC Normoyle submitted the CB for my perusal. Having reviewed the evidence contained in the CB in conjunction with the evidence yielded by my ongoing investigation, I was unable to determine the source of the Baclofen. There was no documented reference from which to conclude that Anna’s treating team had prescribed Baclofen to manage her diagnoses.
Baclofen prescribing and dispensing
In my investigation into the death of Robert Thomas Love (Love) I investigated, inter alia, the prescribing and dispensing regime of Baclofen for alcohol dependency issues and anxietyrelated disorders and handed down my Finding into Death with Inquest, Form 37, on 6 November 2020, published on the Coroners Court of Victoria Website.78
In that matter, my investigation revealed, inter alia, that: i. Baclofen is a synthetic form of gamma-aminobutyric acid (GABA), a major neurotransmitter in the human central nervous system (CNS). It acts by binding to a class of GABA receptors called GABA-B receptors which inhibit neurotransmitter release in the CNS. It is usually prescribed in tablet form in strengths of 10 mg and 25 mg and taken orally; ii. The Therapeutic Goods Administration (TGA) has approved Baclofen in tablet form for the treatment of musculo-skeletal conditions specifically related to, but not limited to, Multiple Sclerosis (MS); iii. Baclofen is often referred to as a muscle relaxant because it has antispastic properties; 76 Email from the Court the “Drugs of Dependence” department of the DHHS as it was then known. On 1 February 2021 DHHS was separated into two departments which respectively became known as the Department of Health (DoH) and the Department of Families, Fairness and Housing (DFFH).
77 Court File, email from DHHS to the Court dated 6 August 2020.
78 See : https://www.coronerscourt.vic.gov.au/sites/default/files/2020-11/RobertThomasLove_083315.pdf and the references cited there.
iv. For non-TGA approved indications, Baclofen may be prescribed for a range of other therapeutic purposes. When medication is prescribed for non-TGA approved indications, the practice is referred to a “off-label” prescribing and is not considered to be “poor clinical practice”;79 v. Although Baclofen is not contraindicated for the treatment of alcohol dependence, the Product Information leaflet, however, contains a warning that Baclofen taken in combination with alcohol increases the risk of respiratory depression and sedation and therefore, it should be used with caution where patients have a history of alcoholism; vi. Despite this caution, there is an emerging and substantial body of literature to support the prescribing of Baclofen as an effective treatment for alcohol withdrawal syndrome; and vii. There is no extant prescribing advice that explicitly warns against prescribing Baclofen to people who suffer anxiety.
With regard to Baclofen toxicity which leads to death, my investigation in the Love matter, revealed further that Baclofen toxicity manifests in a decreased level of consciousness or somnolence, flaccidity, respiratory depression and apnoea. More serious toxic effects of Baclofen include coma, seizures and hypotension (low blood pressure) which leads to death.
To advance my investigation into Anna’s death, it became necessary to interrogate the source of the Baclofen detected during the toxicological analysis of Anna’s biological samples retained at the post-mortem examination. Although the legislative framework in existence at the time of my Finding in the Love matter was still in force at the time of Anna’s death, I am cognisant that the factual matrix in which her death occurred is distinct from the factual matrix in the Love matter. I turn now to consider the impact, if any, of the “off-label” prescribing regime of Baclofen in the context of the circumstances within which Anna’s death occurred.
To assist my investigation into the circumstances in which the death occurred and with a view to consider my prevention role as articulated in the Preamble and Purposes of the Coroners Act 2008 (Vic), I referred the matter to the Coroners Prevention Unit (CPU) for review. I specifically requested the CPU to review the prescribing regime adopted by Anna’s treatment team and her medication dispensing records with the object of identifying the Baclofen prescriber, in order to ascertain whether any prevention opportunities presented in Baclofen79 Richard Day, “Off-label prescribing”, Australian Prescriber, vol 36, 2 December 2013. In Australia, there is no legal impediment to prescribing off-label. The onus is, however, on the prescriber to defend their prescription for a nonTGA approved indication, bearing in mind the best interests of the patient
related prescribing practice(s). Simply put, I focused my investigation on whether the existing “off-label” prescribing regime in relation to Baclofen, represented an opportunity lost for Anna.80
The CPU review confirmed that any medication prescribed for a purpose other than a TGAapproved purpose is “off-label” and therefore ineligible to be dispensed through the Pharmaceutical Benefits Scheme (PBS) government subsidy. Accordingly, when “off-label” prescribing occurs, as in Anna’s case, the dispensing record does not appear on the PBS Patient Summary and to confirm the “off label” prescription, regard must be had to the patient’s medical records and pharmacy drug dispensing records.
Anna’s PBS Patient Summary, however, indicated that two prescriptions for Baclofen were dispensed on 5 August 2019, each for 100 Baclofen tablets, 10 mg in strength. The records indicated further that the prescriptions were issued when Anna was under the care of Dr Michael O’ Ryan of the BPH, according to whom he ‘often prescribed Baclofen to Anna’ as he did with many ‘alcohol rehabilitation patients’ because Baclofen ‘reduces cravings for alcohol and is usually very helpful in keeping patient[s] away from alcohol’. Anna’s BPH records did not indicate when Dr O’Ryan prescribed the Baclofen, however.81
The CPU held the view that any clinician, even Anna’s own treating team, could have been a source of Baclofen prescriptions, but that, by Anna redeeming two prescriptions on the same day, 5 August 2019, is an indication that she may have ‘stockpiled the Baclofen’ and ‘then used it in the fatal incident’.82
I considered the input of the CPU in the context of the body of evidence available to me at this stage of my investigation. Given Anna’s admission to BHH on 4 June 2019 in circumstances not dissimilar to the fatal incident, if a prescriber could be identified by examining the drug dispensing records of the pharmacies listed on Anna’s PBS Patient 80 The Coroners Prevention Unit (CPU) was established in 2008 to strengthen the prevention role of the coroner. The unit assists the Coroner with research in matters related to public health and safety and in relation to the formulation of prevention recommendations. The CPU also reviews medical care and treatment in cases referred by the coroner.
The CPU is comprised of health professionals with training in a range of areas including medicine, nursing, public health and mental health.
81 Court File, CPU Review dated 25 November 2022. It is unclear how the prescription for a non TGA-approved purpose is reflected on the PBS Patient Summary. The evidence indicates, therefore, that it may have been that the Baclofen was prescribed for a TGA-approved purpose.
82 Ibid.
Summary, I determined that I would be enabled to advance my investigation by interrogating whether those prescribers had monitored the safety of their prescribing practice(s), specifically in relation to Anna. In my view, if Anna had been prescribed Baclofen after 4 June 2019, following her detoxification and rehabilitation at BHH, the Swanston Centre and the WCPH then, given her history, Anna’s death may have been preventable in the circumstances.
At my Direction, the seven pharmacies listed on Anna’s PBS Patient Summary were requested to provide their dispensing records for a period of one year leading to Anna’s death. Having scrutinised the dispensing records of the pharmacies identified, no other Baclofen dispensing events were identified. Incidentally, the dispensing records of the BPH Pharmacy indicated that the prescriptions redeemed on 5 August 2019 were issued to Anna on 1 January 2019 by Dr O’Ryan.83
The weight of the available evidence on this fact in issue, therefore, supports a conclusion that the Baclofen which contributed to Anna’s medical cause of death was, in all likelihood, that Baclofen prescribed by Dr O’Ryan on 1 January 2019, approximately one and a half years prior to the fatal incident.
Given that these prescriptions were only redeemed on 5 August 2019, approximately seven months after Dr O’Ryan issued the prescriptions to Anna, the evidence indicates further that the Baclofen used in the non-fatal incident of 4 June 2019, was obtained from another source, unrelated to Dr O’Ryan’s prescription(s) for Baclofen issued to Anna. I was unable to establish the source of the Baclofen used in the non-fatal incident.
The evidence of Dr O’Ryan
At my Direction, the CPU obtained a statement from Dr O’Ryan on 12 October 2021 in which he set out his account of prescribing Baclofen to Anna Lawrence.
According to Dr O’Ryan, he considered Baclofen to be ‘a fairly safe drug’ and Anna was aware of these risks associated with using Baclofen including the risk of ‘sedation etc. if taken 83 Court File, CPU Review Memorandum dated 12 January 2022. The dispensing records of following pharmacies were obtained: i. P J Shay Pharmacy (now Priceline Pharnacy), East Geelong; ii. Neleura Private Hospital Pharmacy, Mornington; iii. Euroa Pharmacy, Euroa; iv. Shulman and Stephens Pharmacy, Camderwell; v. Chemist Warehouse, Shapparton; vi. Chemist Warehouse, Richmond; and vii. Soul Pattinson Chemist, Geelong.
in excess’ (sic). Although Dr O’Ryan provided his summary notes when Anna was discharged from BPH on 6 March 2020, his earlier clinical notes were no longer available. Consequently, the CPU was unable to ascertain whether Dr O’Ryan’s prescribing Baclofen to Anna in January 2019 was reasonable and appropriate in the circumstances.84
In light of this evidence of Dr O’Ryan which I considered in the context of the evidence already before me, which indicates support for the prescribing of Baclofen to patients to manage their alcohol dependency issues, I considered whether by interrogating his decision to prescribe Baclofen in January 2019 any further, I would advance my investigation into Anna’s death.
Given that the prescribing event and Anna’s death were temporally removed from each other by a period of approximately 15 months, I determined that any further evidence from Dr O’Ryan to clarify whether he considered Anna’s clinical history of mental ill-health and her previous suicide attempts before he prescribed the Baclofen, would not advance my investigation. In my view, the prescribing event was too remote from Anna’s agonal event to establish a sufficiently cogent causal nexus between the two events. The evidence, therefore, does not support a conclusion that Dr O’Ryan’s practice of prescribing Baclofen to Anna was connected to her death.
Consequently, I am unable to conclude, on the available evidence, that Anna’s death was preventable in the circumstances.
COMMENTS Pursuant to section 67(3) of the Act, I make the following comments connected with the death.
General comments Victorian Suicide Register
84 Ibid. The clinical discharge summary notes pertained to Anna’s admission to BPH from 7 February 2020 to 6 March 2020.
The VSR indicates the annual frequency of suicides occurring in the state of Victoria has been steadily increasing for the past decade, from 550 deaths in 2011 to a peak of 720 deaths in 2019, then 713 deaths in 2020.85
The annual Victorian suicide rate for the period 2011 to 2019 ranged from 9.9 suicides per 100,000 people in 2011 to 11.0 suicides per 100,000 people in 2017.86
The primary purpose of gathering suicide data in the VSR is to assist coroners with preventionoriented aspects of their suicide death investigations. VSR data is often used to contextualise an individual suicide with respect to other similar suicides; this can generate insights into broader patterns and trends and themes not immediately apparent from the individual death, which in turn can lead to recommendations to reduce the risk that further such suicides will occur in the future.
The December 2022 Coroners Court Monthly Suicide Data Report (CCMSDR) shows an alarming increase in the 2022 deaths-by-suicide rate. Although this rate appears to have increased incrementally since the year 2000 when the Coroners Court of Victoria first started to collect suicide data, the 2022 statistics indicate a 9% increase compared to the data collated in 2021.87
This significant increase in 2022 contrasts with the preceding four years in which deaths-bysuicide in Victoria had seen a plateau in numbers.
Through their investigations, Victorian coroners have observed that social isolation, mental health issues, substance abuse, familial conflict and financial pressures are common stressors in cases of suicide.
So much is still unknown about suicide and, given that every suicide occurs in unique circumstances to a person with a unique history and life experience, possibly there is much we will never be able to quantify and understand. But through recording information about each individual suicide in the VSR, particularly information about the health and other 85 Coroners Court Monthly Suicide Data Report, May 2021 update. Published 16 June 2021.
86 The annual suicide rate is the annual suicide frequency expressed as a proportion of the population in which the suicides occurred. The most common calculation for a crude rate is to divide the frequency of Victorian suicides by the overall population of Victoria in that year, then multiple by 100,000 (to produce the suicide rate per 100,000 people). For example, in 2011 there were 550 Victorian suicides and the population of Victoria at that time was estimated to be 5,537,817 people, so the rate was (550 ÷ 5,537,817) × 100,000 = 9.9 suicides per 100,000 people.
87 Coroners Court Monthly Suicide Data Report—December 2022, published on 6 February 2023. This is the first release of full year Victorian coronial suicide data for 2022 and includes comparative annual figures for 2018 to 2021.
services with whom the person had contact, and then looking at what has happened across time and across people, we hope the VSR can at least lead us to new understandings of how people who are suicidal might be supported better in our community.
Alcohol and suicide
Research has shown that there is an increased rate of suicidal behaviour as well as completed suicide among individuals with an alcohol use disorder.
Post-mortem studies find that alcohol or other drugs at measurable levels play a role in 30– 50% of suicides. Substance misuse predisposes one to suicide by disinhibiting or providing “courage” to overcome resistance to carrying out the act, clouding one’s ability to see alternatives and worsening of mood disorders. The association between alcohol consumption and self-harm or suicide is not entirely clear. Theoretically, consumption of alcohol may influence self-harm or suicide due to the depressant influence of the substance itself, or acute alcohol intoxication contributing to disinhibited or impulsive behaviours.
Comments related to Anna’s death
Although my investigation did not establish that the Baclofen-prescribing event was causally connected to Anna’s death, the factual matrix of this matter accentuated the widespread practice amongst clinicians in prescribing Baclofen to manage alcohol dependency issues.
In this regard, the lack of TGA approval to prescribe Baclofen for alcohol related disorders and alcohol dependency issues results in the prescribing clinician having to take responsibility for researching the clinical efficacy and safety of the drug. The effect of this practice, in turn, results in clinicians taking a subjective approach to Baclofen prescribing practice(s).
If the TGA were to approve Baclofen for alcohol dependency issues and publish prescription guidelines then, determining the clinical efficacy of Baclofen on a patient-by-patient basis would not be at the behest of a treating clinician. Ultimately, by predetermining objective guidelines, safer prescribing practices could be attained and thereby reduce the incidence of Baclofen-related overdose deaths in the State of Victoria.
Statistically, between 2012 and 2021, Anna Lawrence was among 34 Victorians who died in circumstances in which Baclofen overdose was determined to be the medical cause of death.
In most cases, the death resulted from intentional self-harm and in the vast majority of these deaths, the deceased had a history of diagnosed mental ill-health. Further, in approximately
half of these incidents, the deceased had a documented history of simultaneous mental illhealth and alcohol dependence.88
Where the source of Baclofen could be established in these deaths, the statistics held by the CPU indicate that it had been mostly prescribed to treat the deceased’s alcohol dependence and to manage alcohol cravings.
As I have expounded in my Finding, in Australia Baclofen is not approved by the TGA to treat alcohol use disorder or to manage alcohol cravings but there is no legislative prohibition on clinicians to prescribe Baclofen “off-label” for this purpose. The onus is on an individual clinician to be satisfied that prescribing Baclofen for this use is supported by reasonable quality evidence on a patient-by patient basis. The evidence indicates, however, that despite this onus on clinicians, “off-label” prescribing is a relatively common in Australia.89
Dr O’Ryan who was identified as the most likely prescriber of the Baclofen which, as the evidence indicates, contributed to Anna Lawrence’s death stated that he ‘often prescribed baclofen to Anna’ as he did with ‘lots of alcohol rehabilitation patients’ because, according to him, Baclofen ‘reduces cravings for alcohol and is usually very helpful’ as a deterrent from alcohol.
The clinical literature on the topic, while acknowledging that Baclofen may be an effective treatment for alcohol use disorder, recognises the need for high-quality research to support the prescription of the drug and admonishes clinicians to exercise caution when prescribing Baclofen to patients with a history of mental ill-health, suicidality, drug overdose and/or polysubstance use.90 88 CPU Overdose Deaths Register which documents information on all overdose deaths investigated by Victorian Coroners between 2009 and 2021.
i. 24 out of the 34 deaths were attributed to intentional self-harm; ii. In 32 out of the 34 deaths the deceased had a history of diagnosed mental ill-health; and iii. In 17 out of the 34 deaths, the deceased had a history of co-occurring mental ill-health and alcohol dependence.
89 Agabio R et al, “Baclofen for the treatment of alcohol use disorder: the Cagliari Statement”. Lancet Psychiatry, vol 5, no 12, 2018: 957-960. In this journal article, with regard to Baclofen prescribing for alcohol dependency issues, the writer noted that ‘baclofen is prescribed for this reason especially in Australia’.
90 See: i. Addolorato G et Leggio L, “Safety and Efficacy of Baclofen in the Treatment of Alcohol-Dependent Patients”, Current Pharmaceutical Design, vol 16, no 19, June 2010, at 2113.
ii. Dore GM et al, “Clinical experience with baclofen in the management of alcohol-dependent patients with psychiatric comorbidity”, Alcohol and Alcoholism, vol 46, no 6, 2011, at 714-720.
iii. Beaurepaire R, “Suppression of alcohol dependence using baclofen: a 2-year observational study of 100 patients” Frontiers in Psychiatry, vol 3, December 2012.
This admonition is now reflected in a comprehensive document, Guidelines for the Treatment of Alcohol Problems, which was developed and recently updated by a group of Australia’s leading experts in alcohol use disorder and addiction medicine, with funding sourced from the Australian Government.91
The Guidelines include the following admonitions, inter alia, to Baclofen-prescribing clinicians: i. Baclofen may assist in achieving abstinence from alcohol, but the evidence of its efficacy remains lower than first-line medications; ii. Safety concerns with Baclofen treatment include the risk of overdose, dose escalation and seizures. Overdose risk increases with a history of self-harm or unstable mood and, therefore, Baclofen is not recommended as a first-line treatment [for alcoholrelated disorders] and should be prescribed with caution; and iii. Baclofen may be considered in specialist settings as a second-line treatment for selected patients and is contraindicated [as a] first-line medication [for patients with conditions] such as alcohol-related liver disease.
I have considered the medico-legal sources in the context of the circumstances within which Anna Lawrence’s death occurred and in conjunction with the CPU statistics on Baclofenrelated deaths. In my view, the body of evidence supports a conclusion that the lack of TGA approval for Baclofen to be indicated for the treatment of alcohol use disorder(s) may be connected to Baclofen overdose risks in the State of Victoria and, therefore, counterintuitive from a medicines safety perspective.
If there is no existing legislative prohibition on the clinical practice of clinicians to prescribe Baclofen to their patients for alcohol use disorder then, by conjecture or by corollary, if Baclofen was approved by the TGA for alcohol use disorder, the development of associated iv. Crowley P, “long-term drug treatment of patients with alcohol dependence”, Australian Prescriber, vol 38, no 2, April 2015.
v. Minozzi S et al, “Baclofen for alcohol use disorder”, Cochrane Database of Systematic Reviews, issue 11, 2018.
vi. Beaurepaire R et al, “The Use of Baclofen as a Treatment for Alcohol Use Disorder: A Clinical Practice Perspective”, Frontiers in Psychiatry, vol 9, January 2019, at 12.
91 Haber PS et al, “Guidelines for the Treatment of Alcohol Problems, 4th Edition, Sydney: Specialty of Addiction Medicine, Faculty of Medicine and Health, University of Sydney, 2021, at 169.
Product Information and Consumer Medication Information (PICMI) would accompany such approval. In this way, in developing a PICMI leaflet or information sheet, regard may be had to the Guidelines for the Treatment of Alcohol Problems and thereby alert clinicians to any precautions and contraindications for prescribing Baclofen to their patients. Another possibility to be considered is for the associated PICMI to include other harm reducing measures such as controlled dispensing of Baclofen where patients are only provided with a limited quantity of the drug at any given time. A stratagem of this nature could reduce the risk of patients stockpiling dispensed medication, as the evidence indicates Anna Lawrence had done.
It appears that a TGA-approved model of this nature could possibly improve the current “offlabel” prescribing regime of Baclofen for alcohol use disorder where the onus is upon the individual clinician to conduct their own research on a patient-by-patient basis in order to consider whether Baclofen is appropriate for any particular patient. In my view, the weight of the available evidence indicates that a TGA-approved model could reduce the risk of a misguided subjective assessment by an individual clinician of his patient in prescribing Baclofen.
I acknowledge the complexity of the governmental processes that precede the approval of medicines and further, I acknowledge that these processes and initiatives are properly placed in the domain of appropriate professionals in their respective fields of expertise and, therefore, that I may not be aware of all the regulatory and clinical consequences of TGA approval of Baclofen to treat alcohol use disorder.
I recognise and accept that the possibility exists that TGA approval for Baclofen to treat alcohol use disorder may not produce the desired effect of safer prescribing practices.
However, in the same vein, there may be other, more appropriate and effective measures or means to support clinicians and to equip them to make informed decisions when they prescribe Baclofen to their patients for alcohol use disorder.
RECOMMENDATIONS Pursuant to section 72(2) of the Act, I make the following Recommendation:
Pursuant to section 67(1) of the Coroners Act 2008 I make the following findings: a) the identity of the deceased was Anna Lawrence, born 28 February 1956; b) the death occurred on or about 30 April 2020 at 17 Connor Street, East Geelong, Victoria, 3219; c) I accept and adopt the medical cause of death as ascribed by Dr Burke and I find that Anna Lawrence died from combined toxicity to alcohol and Baclofen;
On a background of long-term mental ill- health, alcohol use disorder and complex personal relationship issues, I am satisfied that the combination of these issues contributed to Anna Lawrence’s declining mental health and precipitated her decision to imbibe alcohol in conjunction with taking an overdose of the Baclofen prescribed for treating her alcohol use disorder. The available evidence does not, however, enable me to make any definitive findings to apportion weight to any one of these precipitating factors.
AND, having considered all the evidence, I find that Anna Lawrence deliberately ingested an inordinate amount of the Baclofen tablets, her prescribed medication, while under the influence of alcohol, or vice versa, to intentionally end her own life.
AND FURTHER, the available evidence does not support a conclusion that the conduct of any person or entity can be considered to have contributed to or is connected with Anna Lawrence’s death. Accordingly, I make no adverse comments or findings against any interested party or entity.
I convey my sincere condolences to Anna’s family for their loss.
Pursuant to section 73(1B) of the Act, I order that this finding be published on the Coroners Court of Victoria website in accordance with the Rules.
I direct that a copy of this finding be provided to the following: Jeffrey Lawrence Lisa Westlake Therapeutic Goods Administration Detective Senior Constable Warren Normoyle, Coroner’s Investigator Signature:
AUDREY JAMIESON CORONER Date: 22 February 2023 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an investigation. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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