Coroner's Court of Western Australia

Inquest into the Death of Marjorie Joy JARICK

Inquest into the Death of Marjorie Joy JARICK

Delivered on :23 August 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations : Yes

I recommend that the Department of Health amend the Department of Health Schedule Medicines Prescribing Code to limit the authorisation to prescribe fentanyl transdermal patches to approved specialists for the treatment of pain, as set out in 2.5.8 of the current Schedule (2017). The current system in place for methadone, as set out in 2.5.3, might provide a helpful guide.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a patient at Waikiki Private Hospital when she was found unresponsive by nursing staff shortly after midnight on 10 July 2013. Resuscitation attempts were undertaken and she was taken by ambulance to Rockingham Kwinana District Hospital, where resuscitation efforts were continued but she could not be revived.

The focus of the inquest was primarily on the medical care provided to the deceased in Waikiki Hospital prior to her death, with a focus on the administration of fentanyl and its inherent dangers as a powerful opioid.

The deceased had a number of significant health conditions and was being treated in hospital at the time of her death for a recurrent infection in the groin area that had required surgical excision. The deceased was prescribed opioids, including fentanyl, to manage both her pain immediately after the surgery and to manage her chronic pain.  The prescribing of opioids in those circumstances was standard medical management and had been part of the deceased’s medical treatment in the past.  The use of fentanyl patches for acute pain after surgery was not necessarily standard medical practice, but in this case it was noted to have been prescribed to manage the deceased’s chronic pain rather than acute pain, even though prescribed for the post-operative period.

The Coroner found the deceased died on 9 July 2013 after succumbing to respiratory depression due to the combined dose of opioids she was receiving, but predominantly the fentanyl. The Coroner concluded closer monitoring and observations might have identified that this was occurring, but the signs had been subtle and it was not clear to the nursing staff that the deceased was affected by opioid toxicity.

The Coroner accepted the expert evidence given during the inquest, which supported some limitation on the use of fentanyl patches in the community other than for palliative care, with a strong preference for restriction on the ability of general practitioners to prescribe fentanyl patches in Western Australia. The Coroner, accordingly, made a recommendation to limit the ability to prescribe fentanyl transdermal patches to appropriate specialists.

Catch Words : Use of fentanyl patches : Opioid use : Schedule 9 Medicines Prescribing Code : Misadventure

Last updated: 30-Apr-2019

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