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Inquest into the Death of Daniel James HALL

Deceased

Daniel James HALL

Demographics

26y, male

Date of death

2010-07-31

Finding date

2016-02-10

Cause of death

Multiple drug toxicity and bronchopneumonia

AI-generated summary

Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet every 12 hours. He was a registered drug addict receiving buprenorphine from Dr W. while simultaneously obtaining OxyContin from ENT anaesthetist Dr R., who was unaware of his drug addict status and past opioid dependency. The deceased concealed his current registered drug addict status from Dr R., presenting only a history of past drug problems. Critical clinical lessons include: prescribers must obtain and verify drug addict registration status before dispensing high-dose opioids, particularly for day procedures; communication gaps between practices and specialists contributed significantly; the deceased received 20 tablets dispensed in one supply despite his known history; and real-time electronic monitoring of controlled drug dispensing was not available. Lack of access to contemporaneous drug dispensing records prevented Dr R. from making an informed clinical decision. A secure, real-time prescription monitoring system would have prevented this death.

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

Specialties

anaesthesiaENT surgerygeneral practicepsychiatrypain medicinepharmacology

Error types

communicationsystemdiagnostic

Drugs involved

oxycodoneoxycodone slow releasebenzodiazepinesdiazepamalprazolamzolpidemvenlafaxinechlorpromazineolanzapinepropoxyphenepethidinepholcodinecodeinebuprenorphine

Clinical conditions

opioid dependencybenzodiazepine dependencybipolar affective disorderdrug addictionprescription drug abusenasal polyp (sessile lesion)shoulder injury with chronic painbronchopneumoniaacute respiratory depressionsevere atherosclerosis of left anterior descending artery

Procedures

nasal polyp biopsy under general anaestheticoperative anaesthesia administration

Contributing factors

  • Excessive consumption of OxyContin tablets (approximately 10-12 tablets consumed in 24 hours vs prescribed 1 tablet every 12 hours)
  • Registered drug addict status not communicated to anaesthetist
  • Deceased concealed current drug addict registration from Dr R.
  • Single supply dispensing of 20×80mg OxyContin tablets without daily dispensing safeguard
  • Anaesthetist unaware of deceased's opioid dependency and drug seeking behaviour
  • Lack of real-time electronic prescription monitoring system
  • Communication gap between general practitioner (Dr M.) and ENT specialist/anaesthetist regarding drug history
  • Concurrent benzodiazepine use (diazepam, alprazolam) potentiating respiratory depression
  • Bronchopneumonia present at autopsy
  • Prior CPOP registration and recent failed pharmacotherapy program not disclosed
  • Deceased presenting as credible, charming and reliable despite drug dependency

Coroner's recommendations

  1. WA prioritise the real time collection of dispensing data from all pharmacies for all Schedule 8 and reportable Schedule 4 poisons
  2. All WA real time dispensed medicine data be held in a secure regulated database held by the WA government regulator
  3. WA regulate to ensure the supply or dispensation of all Schedule 8 and reportable Schedule 4 poisons are recorded in the secure regulated database
  4. WA regulate to provide both prescribers, registered pharmacists and authorised suppliers access to that secure data via secure software links to facilitate real time decision making
  5. The current Schedule 8 (controlled drug) dependency register be part of that secure database and provide information along with real time information about medicines dispensed
  6. Information from any register regulated as part of the secure database be similarly available on enquiry for dispensed medicines
  7. Once real time WA dispensing data is available there be a regulated time period to allow commercial practice case management software to be developed; prescribers must then access available data prior to completing any prescription for Schedule 8 or reportable Schedule 4 poisons
  8. All benzodiazepines be included as reportable Schedule 4 poisons
  9. There be a method implemented to assist prescribers and dispensers with decision making around benzodiazepine dependency, and restrictions imposed on recognised unsafe prescribing or supply
  10. CPOP prescribers be given information about a patient's prior CPOP programs and prescribers when seeking authorisation to commence a new program
  11. CPOP prescribers to provide advice when seeking authorisation as to other medications to be prescribed in conjunction with the authorised program medicine
  12. The ultimate aim for the secure regulated database be for all prescription medicines to be captured
  13. The ultimate aim for real time ERRCD data should be for Australia wide access to dispensing data for medical practitioners, registered pharmacists and authorised suppliers
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