Inquest into the Death of Shayne Andrew BERRY
Delivered on :10 February 2016
Delivered at : Perth
Finding of : Deputy State Coroner
1. WA prioritise the real time collection of dispensing data from all pharmacies for all Schedule 8 and reportable Schedule 4 poisons.
2. All WA real time dispensed medicine data be held in a secure regulated database held by the WA government regulator.
3. WA regulate to ensure the supply or dispensation of all Schedule 8 and reportable Schedule 4 poisons are recorded in the secure regulated database held by the WA Government regulator.
4. WA regulate to provide both prescribers, registered pharmacists and authorised suppliers access to that secure data via secure software links to facilitate real time decision making around both prescribing, supplying and dispensing of Schedule 8 and reportable Schedule 4 poisons.
5. The current Schedule 8 (controlled drug) dependency register be part of that secure database and provide that information along with real time information about medicines dispensed on enquiry by a prescriber, registered pharmacist or authorised supplier.
6. The information from any register regulated (e.g. reportable Schedule 4 poisons) as part of the secure database, be similarly available on enquiry for dispensed medicines.
7. Once real time WA dispensing data is available for use there be a regulated time period to allow commercial practice case management software to be developed to facilitate real time access. Once that period is over it be regulated that prescribers access the available data prior to completing any prescription or supply for Schedule 8 or reportable Schedule 4 poisons. The intention is to ensure those with drug seeking behaviour understand prescribers must comply with regulation to enable a prescription to be written.
8. All benzodiazepines be included as reportable Schedule 4 poisons.
9. There be a method implemented to assist prescribers and dispensers with decision making around benzodiazepine dependency, and restrictions imposed on recognised unsafe prescribing or supply. How that is achieved is up to the regulator. Again the concern is not with policing but providing prescribers with a mechanism with which to decline to prescribe in the face of undue pressure from drug seekers.
10. CPOP prescribers be given information about a patient’s prior CPOP programs and prescribers when seeking authorisation to commence a new program.
11. CPOP prescribers to provide advice when seeking authorisation as to other medications to be prescribed in conjunction with the authorised program medicine. This is to include reportable Schedule 4 poisons and amounts with intended reduction regime, if that is applicable.
Australia Wide Dispensing Information
12. The ultimate aim for the secure regulated database held by the WA Government regulator be for all prescription medicines to be captured. If medication warrants a prescription, it warrants monitoring.
13. The ultimate aim for real time ERCCD data should be for Australia wide access to dispensing data for medical practitioners, registered pharmacists and authorised suppliers.
Orders/Rules : N/A
Suppression Order : N/A
Summary : The death of the deceased was examined at inquest, along with two others, Adrian Marcus Westlund & Daniel James Hall, where registered drug addicts obtained drugs which contributed to their deaths, despite the controls imposed by legislation. The three cases are quite different, but all demonstrate the difficulties facing prescribers in attempting to treat patients sympathetically, without the ability to verify information in real time, and still maintain a relationship with their patient which allows them to prescribe in the patient’s best interest.
In all three cases the Commonwealth Prescription Shopping Information and Alert Service advice line (doctor shopping hotline) would not have assisted an enquiring medical practitioner despite it being a “real time” monitoring tool due to the fact none of the deceased fulfilled the criteria for “doctor shopping” status, although clearly demonstrating drug seeking behaviour.
The drugs in question were Schedule 8 (opioids) and Schedule 4 (benzodiazepines) and the issue of tolerance in individuals being a relevant factor.
The deceased was a 44 year old male who had a past history of heroin addiction. He had attempted opiate substitution programs in Queensland (methadone) and WA (Suboxone).
The substitution program in WA using Suboxone saw him registered as a drug addict with the WA Department of Health in December 2010, due to expire in December 2012. The deceased attempted to continue with his Suboxone program (CPOP) but due to the absence of appropriate prescribers in Karratha in early 2011, his compliance with the program lapsed.
His partner indicated that while the deceased’s compliance with the Suboxone program failed, he did not return to using heroin or opioid medication in the way he had in the past. However, he compensated due to his other illnesses, with heavy diazepam use.
The deceased’s partner attempted to wake the deceased at approximately 11am on 24 November 2012 but was unsuccessful. He was still asleep and she assumed he was sleeping off the effect of drugs.
The Coroner found the deceased had taken an excessive amount of the prescription oxycodone. In conjunction with his other sedating medication he fell into a state of deep sedation which prevented him from protecting his airways. At some time the deceased vomited and aspirated and died.
The Coroner found there was no indication the deceased wished to die.
The Coroner found death arose by way of Misadventure.
Catch Words : Schedule 8 poisons : Schedule 4 poisons : Dependency Register : CPOP programs : Doctor Shopping : Misadventure
Last updated: 13-Oct-2016
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