Finding into death of Jessica Higgins

Contributing factors

• Inadequate post-discharge planning following ketamine infusion and opioid rotation
• Lack of in-person clinical review before significant dose increase on 26 May 2017
• Poor documentation of clinical communications between treating practitioners
• Polypharmacy with sedative agents (methadone, pregabalin, diazepam)
• Ambiguous medication instructions regarding methadone dosing at discharge
• Possible patient confusion regarding medication doses due to sedation and poorly documented prescribing changes
• Failure to consider alternative opioid therapies such as MATOD or buprenorphine
• Absence of emergency management plan for recurrent pain post-discharge
• Combination of medications with known respiratory depression risk

Coroner's recommendations

1. The Royal Australian College of General Practitioners and the Faculty of Pain Medicine should reiterate to their members the importance of considering buprenorphine in chronic pain management in appropriate cases
2. The Royal Australian College of General Practitioners and the Faculty of Pain Medicine should reiterate the risks associated with patients prescribed multiple and concurrent medications with sedative properties, and that frequent reviews of patients ought be undertaken in a face-to-face setting to assess for adverse signs and symptoms
3. The Royal Australian College of General Practitioners and the Faculty of Pain Medicine should reiterate to their members the importance of practitioners ensuring that all interactions with their patients, especially those with multiple providers, are documented in clear, written form in the patient's medical record, and that all patients are instructed in clear, written terms regarding their medication usage and doses to avoid potential adverse outcomes
4. The Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists should include in their forthcoming guidelines on ketamine infusion specific guidance on post-discharge planning that addresses how to communicate clinical decision-making surrounding changes in dosage of opioid medication and what information will be required before making any such changes