Coronial
SAcommunity, workplace

Coroner's Finding: Murray, Erin Paige and Patterson, Amy Jean

Deceased

Erin Paige Murray and Amy Jean Patterson

Demographics

female

Date of death

2014-07-25, 2015-10-16

Finding date

2019-10-23

Cause of death

pentobarbitone toxicity

AI-generated summary

Two veterinary-associated women (a veterinary student and a practicing veterinarian) died from pentobarbitone toxicity via ingestion, with evidence of intentional self-harm. The coroner identified that both women had access to lethal pentobarbitone through veterinary workplaces despite it being a Schedule 4 substance requiring only public exclusion. Key clinical lessons: pentobarbitone, a highly concentrated and rapidly fatal veterinary euthanasia drug, was stored in unlocked cupboards/drawers in workplace settings where colleagues and students could access it. The coroner found that Schedule 8 classification (requiring locked storage) would have prevented access by non-veterinarians. Mental health support systems were inadequate in the veterinary profession. Recommendations included legislative amendment to regulate all veterinary premises, up-scheduling pentobarbitone to Schedule 8 nationally, and developing holistic mental health and mentoring programs for veterinary staff dealing with documented elevated suicide rates in this profession.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

veterinary medicinepsychiatryoccupational and environmental health

Error types

systemdelay

Drugs involved

pentobarbitonepentobarbitallethabarb

Clinical conditions

depressionmental health disordersuicidal ideation

Contributing factors

  • inadequate storage security of Schedule 4 pentobarbitone
  • accessibility of lethal substance to non-veterinarians in workplace
  • mental health difficulties and depression
  • high stress and academic/occupational pressures in veterinary profession
  • absence of mental health support systems in veterinary workplaces
  • lack of regulatory oversight of non-hospital veterinary clinics
  • unclear regulatory distinction between Schedule 4 and Schedule 8 requirements

Coroner's recommendations

  1. The Veterinary Practice Act 2003 be amended to provide the Veterinary Surgeons Board of South Australia with jurisdiction over all veterinary practices (not just accredited hospitals) to regulate storage of and record-keeping requirements for pentobarbitone and other controlled substances
  2. Pentobarbitone in injectable form be up-scheduled within the Commonwealth Poisons Standard to Schedule 8 to require locked container storage at all times when not in use
  3. Professional bodies and the veterinary profession address the concerning incidence of suicide associated with the profession through holistic solutions including development of mentoring programs, mental health support programs, and acknowledgment of occupational stressors such as long hours and high stress levels affecting veterinary surgeons, nurses, students and other associated staff
Full text
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Source and disclaimer

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