Hydromorphone thefts reveal systemic misconduct risks

Fiona Stanley Hospital. Image: Don Pugh via Facebook

How could a pharmacist steal an “extraordinary amount” of narcotics from two major public hospitals?

The activities of Matthew Foster, a senior clinical pharmacist at Fiona Stanley Hospital, have highlighted systemic issues regarding the supply and management of S8 drugs in public hospitals, an investigation has found.

Mr Foster, who the report found came to the hospital “highly addicted” to hydromorphine, circumvented controls for almost 14 months without detection, stealing large quantities of Schedule 8 drugs: mainly hydromorphone but also including oxycodone, oxycodone/naloxone and fentanyl.

The Corruption and Crime Commission investigation found that the checks and balances at FSH, as well as at Sir Charles Gairdner Hospital, were inadequate to detect Mr Foster’s conduct.


How did it happen?

Matthew Foster had been an outstanding pharmacy student, and had been named Pharmacy Student of the Year in 2008 at the University of Western Australia. Soon after graduation he was employed by WA Health and undertook an internship at Sir Charles Gairdner Hsopital, where he became fully qualified.

But following the death of his 10-year-old daughter in February 2014 from an unknown degenerative neurological disease, Mr Foster became addicted to hydromorphone. There was “limited” intervention by WA Health to see how the tragedy had affected him, the report noted.

“It is clear Mr Foster became addicted to opioids at SCGH,” the CCC investigation found. “Systems in place to manage and control Schedule 8 drugs at SCGH were inadequate and easy to circumvent without detection.”

Mr Foster began work at Fiona Stanley Hospital in October 2014.

For some time, the thefts had looked like legitimate supplies of S8 drugs from hospital pharmacies to wards and units, the investigation noted.

The chief pharmacist, Barry Jenkins, at FSH described the amount of drugs diverted as “extraordinary” and said that when the thefts came to light, “my life passed before my eyes”. Mr Jenkins then acted immediately on the misconduct.

“The amount and regularity of Mr Foster’s use indicated he required a substantial quantity of opioids to fuel his addiction. Without building a degree of tolerance, the dosage was likely to be fatal,” the report said.

On 15 February 2016 the Commission was alerted to suspected serious misconduct at Fiona Stanley Hospital regarding “systemic” theft of hydromorphone over a possible period of 14 months.

Less than 48 hours later, CCC investigators found that in the week prior, Mr Foster had entered the FSH pharmacy after normal working hours on three occasions. During this time he stole 1.5 grams of hydromorphone from the pharmacy safe.

He was arrested on 19 February and made admissions regarding possession and use of hydromorphone. Mr Foster was charged, convicted and sentenced for stealing and possession of 17.78 grams of hydromorphone and 11.96 grams of oxycodone. These charges related to only 46 of 130 unauthorised S8 drug supply transactions assessed by the CCC to have been made from the FSH pharmacy safe. There were also five such occasions at SCGH.

Mr Foster was later sentenced in the Fremantle Magistrate’s Court to a 12-month prison term, suspended for 12 months, as well as an 18-month community based order. He was also ordered to pay restitution to WA Health.

His defence counsel told the Court that Mr Foster had dealt with his daughter’s death – for which he blamed himself – by immersing himself in work, causing “enormous” stress.

“There was obviously extreme grief and in Mr Foster’s case, also guilt,” he told the Court.


Broader implications

The Corruption and Crime Commission report found that Mr Foster’s case raises concerns about the broader serious misconduct and corruption risks at public hospitals.

For example, some WA Health records required by legislation to be produced on demand were missing, inhibiting the investigation and prosecution processes.

The CCC investigation identified significant deficiencies in detecting unauthorised supply or use of S8s, as well as exposing an inability to identify, track and audit records of their unauthorised supply.

The report highlighted several risk areas regarding public hospitals:

  • after-hours access to the pharmacy safe;
  • not reconciling supply by the pharmacy and receipt at a ward or unit;
  • substandard practices around the use of requisition forms; and
  • inadequate management of registers.

The Commission acknowledged that work was underway at both hospitals to prepare new policy, procedures and practical guidance for staff handling S8s, but warned that a key policy reform approved by hospital management in September 2016 had not yet been implemented, and mandated quarterly audits were yet to be conducted.

While the hospitals maintained that the necessary changes remain “in transition” and a “work in progress,” the Commission said it believes serious misconduct and corruption risks in Western Australian hospitals remain significant until the work is completed.

The report made a series of recommendations to help reduce the likelihood of such misconduct happening again.

  • After-hours pharmacy and safe access: give consideration to mandatory audits for all after-hours supply or dispensation, prohibiting after-hours solitary access and increasing security and monitoring through technology.
  • Reconcile supply and receipt: implement procedures that mandate and reinforce the separation of duties in relation to each act required in the supply process.
  • Regular compliance checks including regular checks on randomly selected staff, wards and units, and independent audits to measure policies, procedures and practices compliance.
  • Develop and implement registers practices to enable registers to be produced without delay when required; provide heightened security and audit the movement of registers.
  • Update and consolidate procedures and practices to align with the current statutory regime.
  • Implement a forum for chief pharmacists of public hospitals to share knowledge about drug diversion risks and solutions.
  • Modernise requisition and register system.
  • Enhance automated systems: take action to maximise S8s on the imprest list and take action to inhibit automated systems allowing a pharmacist to supply imprest drugs manually.
  • Progressively introduce automation to public hospitals.

The full report can be read here.

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