Falling between the cracks

Coroner calls delay of real-time monitoring in WA “frustrating” and pleads for urgency following the death of a young army veteran

The WA Coroner has found that real-time monitoring would have saved the life of a young man who died in July 2014 after taking a fatal quantity of oxycodone.

Twenty-four year old Matthew Tonkin had been visiting multiple doctors in the months before his death in attempts to gain access to oxycodone and other medicines.

Prior to his death, he had overdosed several times but had been rescued with naloxone treatment.

The young man had joined the Australian Defence Force (ADF) on his nineteenth birthday, and was deployed to Afghanistan in June 2012.

In his recruiting psychology report, Mr Tonkin was described as a mature candidate who presented as confident, robust and well-adjusted.

However while on deployment for just five months, he witnessed the death and maiming of close friends and associates.

He also sustained a hip and ankle injury while doing physical training, and was provided with a significant supply of oxycodone while in hospital.

When he returned to Australia in October 2012 for treatment and rehabilitation, Mr Tonkin was a changed man.

His partner noticed he would wake up sweating profusely due to nightmares about what he had experienced while on deployment.

In May 2013 he was diagnosed with post-traumatic stress disorder (PTSD), and it was about this time that Mr Tonkin began complaining of severe hip pain and the commencement of back pain, and sought an increase in pain medication.

He was prescribed oxycodone by his medical officer, and the next month was additionally prescribed diazepam.

In June 2013 Mr Tonkin sought a discharge from the army, and it was about this time that he began seeking more and more oxycodone, telling his family GP that he could not stop taking it for chronic pain.

Mr Tonkin increasingly showed signs of substance abuse. He was admitted to the health clinic at his military barracks in August 2013 following an overdose of oxycodone tablets.

This became the first of three overdoses within a period of just four months.

In January 2014 Mr Tonkin moved back to Western Australia to live with his father, where he continued to attend various doctors and receive prescriptions for oxycodone, tramadol, alprazolam and prazosin.

By mid-May 2014, GPs who saw Mr Tonkin were refusing to prescribe oxycodone, partly because his drug-seeking behaviour was so apparent.

The delay of the implementation of the proposed real-time collection and reporting of Schedule 8 drugs in WA is frustrating.—WA Coroner

On 1 July 2014 Mr Tonkin attended a medical practice in Claremont and saw a GP who prescribed him controlled-release oxycodone – 28 tablets of 20mg and 28 tablets of 80mg.

She told the Perth Coroner’s Court that he had appeared to be honest and genuinely distressed about his pain, and did not display any signs of intoxication or drug seeking.

However she did not call the prescription shopping service to check whether he was overprescribed or recorded as an addict.

Two days later, on the morning of 3 July, Mr Tonkin was dead.

A post mortem revealed fatal levels of oxycodone and presence of alprazolam and metabolites of diazepam, as well as widespread acute bronchopneumonia throughout both lungs.

His death was found to be accidental.

Perth Coroner Barry King suggested that Mr Tonkin’s tolerance to opioids would have decreased over June 2014 after being turned away from medical practices on numerous occasions.

While there were information systems in place in 2014 to enable prescribers to identify prescription shopping, each of them “were limited to some degree”, said the Coroner.

GP evidence indicated that obtaining a veteran’s medical records from the ADF was a “difficult, time-consuming process”.

Mr Tonkin’s family GP told the Coroner’s Court that the deceased would not have been prescribed a lot of the medications had a real-time monitoring system been in place.

The GP that prescribed what ended up being the fatal dose for Mr Tonkin said real-time monitoring might have saved his life.

In what the Coroner labelled a “bitter irony”, the GP had received a letter from the WA Department of Health notifying her that Mr Tonkin was a notified drug addict—39 days after he died.

Altogether from 1 January 2014 to 3 July 2014, Mr Tonkin had seen 24 different doctors in Queensland and Western Australia, and had 99 consultations. He attended 16 different pharmacies and obtained 23 different medications over 99 attendances. He was given 27 prescriptions for oxycodone, of which three were for oxycodone with naloxone. He was given 15 prescriptions for benzodiazepines: 11 for diazepam and four for alprazolam.

The inquest heard that while the WA Department of Health has commenced replacing its database to enable real-time reporting of all WA prescriptions, it is not yet operational.

WA Chief Pharmacist Neil Keen said that while he was hopeful the WA database for real-time reporting would be operational by October 2019, “he had thought the same thing about seven years ago”.

“The evidence suggests that the deceased would have obtained no prescriptions for oxycodone in WA had a national real-time prescription reporting system been available or had the GPs in WA had access to his ADF medical reports, said the Coroner.

“Mr Keen’s evidence described above does not inspire a lot of confidence that a real-time system will be functioning this year,” said the Coroner.

“The delay of the implementation of the proposed real-time collection and reporting of Schedule 8 drugs in WA is frustrating.

“Here we are almost four years later with a delay of another two years expected for WA alone. For what it is worth, I add my voice to the chorus pleading for urgency,” he said.

Pain experts also gave evidence on the current over-reliance on drugs to treat chronic pain, with the Coroner finding that GPs need up-to-date education on treating chronic pain.

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