Finding into death of Melanie Diane Doherty

Contributing factors

• Lack of best practice medication reconciliation at Eastern Health
• Incomplete best possible medication history documentation
• Prescription of medications (tapentadol, oxycodone) that had been ceased in hospital
• Inadequate medication review prior to discharge from Eastern Health
• Lack of medication reconciliation processes at Queen Elizabeth Centre
• Unrestricted access to takeaway methadone bottles in residential setting
• Possible self-administration of additional drugs beyond prescribed medications
• Undocumented presence of diazepam (not prescribed)
• Multiple medications with respiratory and central nervous system depressant effects
• No verification of medications with GP or other sources at QEC

Coroner's recommendations

1. Queen Elizabeth Centre review current processes and clinical staff training for recording and managing medications for residential program participants, including best practice best possible medication history steps, medication reconciliation processes and clinical staff responsibilities
2. Eastern Health offer admission to parents who need to stay with their baby prior to discharge when medication requirements are identified, with assessment, care plan, and medication management documented consistently with Eastern Health practices; if parent declines admission, they will be unable to stay overnight