Cowley-Perch, Donna

Contributing factors

• Inadequate regulatory controls over storage and access of injectable pentobarbitone in veterinary clinics (Schedule 4 rather than Schedule 8)
• Unlocked storage of pentobarbitone in clinic cupboard with access by multiple staff
• No recording or auditing system for pentobarbitone use
• Insufficient product labelling guidance on secure storage to prevent human misuse
• Limited awareness within the veterinary industry of the extent of pentobarbitone misuse for suicide
• No formal communication to veterinarians of changes to product safety data sheets
• Lack of education and support for mental health and suicide prevention in the veterinary workplace
• Deceased's unrecognized mental health crisis in the days before death

Coroner's recommendations

1. The Therapeutic Goods Administration (TGA) should upschedule pentobarbitone in injectable form to a Schedule 8 drug in the Commonwealth Poisons Standard
2. Queensland Health and all State and Territory regulatory authorities should adopt the TGA's upscheduling and implement stricter controls, or alternatively introduce stricter regulations for Schedule 4 pentobarbitone in line with Schedule 8 controls
3. Manufacturers of pentobarbitone should introduce a warning on product labels and Safety Data Sheets that the drug must be stored in a locked safe/vault/receptacle, with contextual information about why this is important
4. Manufacturers should notify State Veterinary Boards when important changes to Safety Data Sheets are made so they can publish bulletins to registered veterinarians
5. Distributors of pentobarbitone should ensure only authorized persons can order and take physical delivery of the drug; delivery should not be made to any staff member
6. Virbac Australia Pty Ltd should encourage employees to report knowledge of adverse events relating to their products, including anecdotal evidence, to enable proactive investigation and response
7. Veterinary professional organizations should improve education and support to the industry regarding: (i) obligations to manage pentobarbitone consistent with Workplace Health and Safety, Health, and criminal law regulations; (ii) important changes to drug Safety Data Sheets through coordinated communication; and (iii) suicide awareness and prevention including advertising campaigns, mentoring programs, mental health first aid courses, and counselling hotlines