Could real time monitoring have helped Alissa?

legal medical tribunal doctor overprescribing

A coroner has highlighted the “pressing need” for real time monitoring to help prevent accidental overdose deaths like that of a young mother

At an inquest into the death of 26-year-old Alissa Campbell in Sydney, coroner Harriet Grahame outlined the extreme difficulty medical practitioners had in obtaining a clear picture of her medical history and medicines use.

A spreadsheet of Ms Campbell’s prescriptions and those of her mother – from whom she sometimes obtained Valium – was described as a “startling document outlining a very large number of prescription medications obtained from different doctors and filled at a variety of chemists, sometimes even on the same day”.

In the six months leading up to her death, Ms Campbell had seen 13 GPs.

“However, as the inquest progressed it became increasingly clear that no one practitioner had a complete picture of her health needs or indeed her current medications,” the coroner noted.

“While some of the doctors prescribed a range and volume of medication that was acceptable in isolation, the total picture that emerged was disturbing.”

One GP, who prescribed “cautiously”, was unaware of Ms Campbell’s long history of migraine and of troubling benzodiazepine use, for example.

The coroner noted that this doctor could not know that “that Alissa appeared to be developing a significant dependence on prescription medication as 2015 wore on”.

“Alissa clearly understood that by visiting different doctors she could obtain the medication she needed. She was then careful to get it dispensed at different pharmacies, sometimes even on the same day,” the coroner observed.

“Alissa appears to have visited doctors who were prepared to use private prescriptions and she asked for them directly.”

Ms Campbell had a “substantial” medical history, the coroner noted, and over the years had experienced conditions including recurrent back pain, sciatic nerve problems, iron deficiency anaemia, seizures, migraines, Graves’ disease, obesity, anxiety, self-harm, suicidal ideation, post-natal depression and depression.

“There is no doubt that she was a complex patient, with a range of needs. Over the years she attended numerous doctors and received a wide range of medication. As well as any physical and mental health problems she experienced, Alissa was also troubled by extreme interpersonal trauma and the effects of family dysfunction.”

On the day Ms Campbell died, her mother was aware that she had taken five Valium tablets, but it was not known whether she had taken other medicines.

Her partner found her in what appeared to be a deep sleep, and when he was unable to rouse her he assumed she had passed out.

He told the court that he had been becoming “increasingly concerned” about her prescription drug use and took several photographs and a short video of her on the couch.

He “explained that he wanted to show Alissa how she actually looked and acted when she used prescription medicine, as in the past she had not believed him,” the coroner noted. She observed that he had not understood that Ms Campbell’s condition was life-threatening and that he was genuinely concerned about her.

Her brother’s girlfriend later saw Ms Campbell on the couch and asked her brother to check on her as she was sleeping in a “weird position”.

Her brother called an ambulance but Ms Campbell was later pronounced dead at the scene.

An autopsy listed the direct cause of death as “multiple drug toxicity”.

Prescription drugs present in Ms Campbell’s system at the time of her death included various opioids – codeine, morphine and oxycodone – as well as various benzodiazepines, and doxepin and sertraline.

A specialist general physician and toxicologist analysed these results and found that Ms Campbell’s death was predominantly caused by the combination of codeine and doxepin.

“It is important to state that there is no evidence to suggest that Alissa’s death was intentionally self-inflicted. Rather, it appears to have been an accidental overdose that occurred while she was eating or resting.”

Prescriber focus

Between 19 January 2015 and 13 July that year, one of Ms Campbell’s doctors wrote private scripts for her which added up to 800 diazepam tablets: 700 at the 5mg dose, and 100 at 2mg.

This doctor also provided PBS scripts across those seven months for dothiepin, prochlorperazine, oxycodone + naloxone, tramadol and sertraline. At one stage, he issued a new script despite having written one for 200 diazepam tablets nine days earlier. He gave evidence that she “may have” lost the earlier script but that he could not recall.

The coroner said that it was “impossible” that this doctor could miss clear red flags that Ms Campbell was developing a problem: she was travelling long distances to see him, was requesting certain drugs by name and requesting large quantities, as well as private scripts.

At one stage a pharmacist rang him to ask when dispensing should occur: on 28 January 2015 Ms Campbell had presented the script to the pharmacy despite the doctor’s having noted that it should be filled until 10 February.

“Even this did not make him question what was going on,” the coroner noted. She said she intended to refer this doctor to the Medical Council.

Another doctor, who worked for an after hours medical service that Ms Campbell and her family sometimes used for home visits, exhibited “troubling” conduct, the coroner said.

“He saw Alissa on five occasions and prescribed various drugs. He gave intramuscular injections on three occasions, morphine on 28 January 2015 and pethidine on 19 April 2015 and again on 26 May 2015,” she said.

“His medical records are lacking and the choice of medication is likely to have been inappropriate. Given this doctor’s lack of cooperation with the court, it is impossible to know if the doctor would attempt to justify his treatment decisions. In my view it is appropriate to refer him to the Medical Council.”

The coroner said that the case highlights the urgent need for the NSW Government to “do more” about the frequency of accidental overdose in the state.

“It was extremely difficult to get an accurate picture of the medical care and prescriptions being provided to Alissa prior to her death. While it is possible to obtain PBS records and Medicare records for the purpose of this inquest, it is very difficult to know if Alissa was also attending any doctor on a non-Medicare basis or if unidentified doctors may have been prescribing on private scripts,” she said.

“The tragic evidence in this inquest, once again demonstrates the need for improved monitoring of the prescribing of certain types of drugs.

“A system that has the capacity to immediately identify a patient’s current prescriptions would clearly assist doctors and pharmacists to prescribe and dispense more safely. It would be particularly useful in caring for complex patients like Alissa who accessed a number of doctors and pharmacies at any one time.”

She said it was easy to identify specific examples, such as the occasion in March 2015 when one doctor – the first Ms Grahame said she would refer to the Council – prescribed sertraline and Targin on a PBS script and a large quantity of diazepam on a private script.

On the same day, another doctor prescribed tramadol and prochlorperazine on the PBS. Each script was taken to a different pharmacy.

Two days later a third doctor prescribed Panadeine Forte and another 20 tramadol, and the script was filled at a different pharmacy yet again.

“This demonstrates how no one person had enough information to give Alissa the support and assistance she needed.”

The fact that NSW is waiting on a Commonwealth real time monitoring system to be implemented, rather than tackling its own as Victoria has done, was “both frustrating and depressing,” the coroner said, and called for fast action from the NSW Government.

“The question must be asked, where is NSW’s commitment to this important issue?”

She said that doctors should explicitly discuss the risk of overdose with patients; that wider awareness of naloxone was required within the community; and that if an ambulance had been called earlier, Ms Campbell’s life could have been saved.

The lack of movement on real time monitoring in NSW has been pointed out recently by pharmacist bodies including the Pharmacy Guild and PSA state branches.

In May 2018, the presidents of both branches wrote to NSW Health Minister Brad Hazzard and Chief Pharmacist Judith Mackson to urge them to implement such a system.

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