Inquest into the death of Lauren Maree Johnstone

Contributing factors

• Incomplete medication history obtained by treating surgeons and anaesthetist
• Lack of communication between treating doctors regarding concurrent procedures and medications
• Patient non-disclosure of over-the-counter medications and additional planned surgery
• Prescription of opioids (oxycodone, tramadol) in post-operative period without full awareness of existing sedative medication regime
• Use of non-prescription sedating medications (Restavit containing doxylamine, codeine) not disclosed to prescribers
• Multiple surgeries in short timeframe (breast reduction 27 November 2014, bladder reconstruction 20 December 2014, facial surgery 5 January 2015)
• Absence of mandatory prescription monitoring system at the time
• Pre-existing obesity and sleep apnoea increasing risk of respiratory depression and positional asphyxia
• Cumulative sedative effects of polypharmacy

Coroner's recommendations

1. The Therapeutic Drugs Authority should consider whether promethazine and doxylamine are appropriately scheduled in the Poisons Standard, or whether further restrictions are warranted given risk of misuse in combination with other sedating medications
2. The ACT Health Minister should declare tramadol, doxylamine and diazepam to be monitored medicines under the DORA system
3. The ACT Health Minister should consider widening the scope of the DORA system to include all medicines listed in Schedules 3 and 4 of the Poisons Standard, or alternatively, prescription and over-the-counter medications with significant sedating or adverse effects when combined with opioids or benzodiazepines
4. The ACT Health Minister should add functionality to DORA to highlight where a patient has demonstrated drug-seeking behaviour, including when a medication contract has been signed
5. The ACT Health Minister should make access to and use of the DORA system mandatory for all ACT prescribing physicians and pharmacists prior to writing and/or dispensing prescriptions
6. CAPS Clinic and Sole Vita Day Surgery should alter pre-admission forms to expressly prompt patients to list all over-the-counter medications they are presently taking or take frequently, with examples of common brand names
7. The Royal Australian College of General Practitioners, Australian and New Zealand College of Anaesthetists, and Royal Australasian College of Surgeons should conduct information campaigns with members to encourage specific prompting (verbally and on forms) of patients regarding over-the-counter medication consumption when taking patient histories