Inquest into the Death of Fisher, Hayley Bree

Contributing factors

• inadequate security of Schedule 8 drugs at point of patient administration
• mechanical PCIA device not secure against diversion
• history of depression and anxiety
• recent substance misuse (oxycodone, benzodiazepines, panadeine forte)
• untreated or inadequately treated mental health disorder
• grief following mother's death
• no previous incidents at hospital to alert staff to PCIA diversion risk

Coroner's recommendations

1. The Department of Health and public hospitals should continue to review and improve the means by which unauthorised access to Schedule 8 drugs at hospitals is controlled, particularly at the point of the administration of the drugs to patients
2. Consideration should be given to implementing secure, electronically controlled PCIA devices with locked containers for drug reservoirs
3. Continue and enhance staff training to raise awareness of drug security procedures and the consequences of misconduct
4. Implement improved reporting and investigation systems for drug discrepancies (such as Operational Directive OD 0377/12)