Inquest into death of ABC (a pseudonym)
Deceased
ABC
Demographics
unknown
Date of death
2023-05-16
Finding date
2024-09-11
Cause of death
VAD oral substance toxicity; underlying conditions: ischaemic heart disease, emphysema, COVID-19 infection
AI-generated summary
An elderly person (ABC) died from self-administering a voluntary assisted dying (VAD) oral substance that had been prescribed for their spouse but not collected for return after the spouse died. ABC was grieving, suffered depression, and had been a contact person with no background checks or suitability assessment. The coroner found the VAD self-administration process fundamentally unsafe: dangerous S8 medication was handed to an unvetted lay person with no oversight, stored in their home for months, and a reminder to return it essentially reminded them the substance was available. Had timelines for return been observed, death could possibly have been prevented. The coroner criticised the departure from a safer model requiring health practitioner supervision at administration. Key failures: no background/identity checks of contact persons; medication not kept under health professional control; no monitoring of where/how substance was stored; contact persons often grieving family members; insufficient consideration of medication safety versus patient autonomy.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Clinical conditions
Contributing factors
- Unused VAD substance not returned within prescribed timeline
- Contact person had no background checks or suitability assessment
- Contact person in state of profound grief after spouse's death
- Contact person had history of depression, ceased antidepressant medication
- VAD substance kept in home with no health professional oversight
- Medication reminder constituted reminder of available end-of-life option
- No practical oversight by QVAD-SPS of substance storage or security
- VAD patient and contact person were elderly, inexperienced with medications
- No system to prevent contact person having two VAD doses available simultaneously
Coroner's recommendations
- Change VAD oral self-administration process so the substance remains under direct control of an authorised health professional at all times until administration
- Require health practitioner attendance at the location when VAD oral substance is to be self-administered
- Allow patient to choose time, date and place of administration but require 7 days' notice for health practitioner to deliver the substance
- Health practitioner to oversee correct set-out of medication, remain present during self-administration, and confirm death
- Implement background checks and identity verification for contact persons (currently none conducted)
- Implement system to prevent VAD patients having two VAD doses supplied simultaneously
- Change approach to recovery of unused VAD substances to eliminate prolonged follow-up contact with grieving contact persons
- Government should adopt the safer approach proposed in the Model Bill by Professors Ben White and Lindy Wilmot, rather than the Queensland Law Reform Commission model
Further listening
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