Coroner's Finding: TATCHELL Melissa Jay

Contributing factors

• Inappropriate prescription of high-dose oxycontin by locum doctor inexperienced with opioids
• Failure to verify patient's claims regarding prior hospital oxycodone dosing
• Inadequate supervision of overseas-trained doctor during prescribing decisions
• RAH staff failure to review or challenge oxycontin dosage on admission despite documented symptoms
• Patient self-medication with 80mg tablets in hospital despite risk
• RAH discharge with high-dose oxycontin tablets in patient possession
• Erroneous advice to patient to break slow-release tablets in half
• Concurrent benzodiazepine (diazepam) use increasing CNS and respiratory depression
• Profound underweight condition (BMI 11.8) increasing drug toxicity risk
• Inadequate medication governance at residential facility
• Loss of medication administration records preventing investigation
• Delayed police investigation due to incorrect initial cause of death assumption

Coroner's recommendations

1. Chief Executive of Australian Health Practitioner Regulation Agency should advise all medical practitioners supervising overseas-trained doctors in general practice to specifically oversee prescription of opioid medications, requiring supervisees to seek advice before prescribing opiate-based medications
2. Chief Executive of Australian Health Practitioner Regulation Agency should advise all registered psychologists to be vigilant in identifying signs of overmedication in clients and consider advising referring GPs of such observations
3. Director of Emergency Department and Director of Critical Services at Royal Adelaide Hospital should instruct medical staff to review medication requirements of patients kept in Emergency Department for extended periods, particularly those prescribed opioids showing signs of excessive sedation
4. Director of Emergency Department and Director of Critical Services at Royal Adelaide Hospital should instruct nursing and medical staff to sight medication in possession of presenting patients and remove medication when patients are admitted to general wards or Short Stay Ward
5. Director of Emergency Department and Director of Critical Services at Royal Adelaide Hospital should take necessary steps to prevent patients in Emergency Department Short Stay Ward from self-medicating
6. Director of Emergency Department and Director of Critical Services at Royal Adelaide Hospital should ensure clinical staff are aware of the need to avoid advising patients to break slow-release medications such as oxycontin