Laxatives need pharmacist advice: coroner

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A coroner has recommended laxatives be rescheduled to Pharmacist Only following the death of a woman who was taking up to 800 Dulcolax tablets a day

Adelaide woman Claudia La Bella died in June 2014 as a result of aspiration of gastric contents complicating laxative abuse, South Australian state coroner Mark Johns found.

Ms La Bella and her husband had been making bulk purchases of Dulcolax at the Chemist King pharmacy in Hectorville – but the coroner ruled that the pharmacist, Ms Tan, had no knowledge of the sales and had not been asked about them by a retail manager.

At the time of Ms La Bella’s death, she was 28 years old and weighed 35kg. She had told her husband and family that she suffered from terminal ovarian cancer, and over time she lost weight, ceasing eventually to eat any solid food, saying it was difficult to keep it down.

Her husband gave evidence that he was buying her boxes of Dulcolax from the pharmacy, which Ms La Bella had told him was to “flush toxins” from chemotherapy from her body.

He said that he bought the Dulcolax for her each week and that there were always at least two or three boxes in the house, a number which rose to 10 or 15 towards the time of her death. He said that on one occasion he bought 15 boxes for her at once. The laxatives were costing up to $500 a week.

He said his understanding was that a doctor would inject chemotherapy treatment into the Dulcolax tablets, which would enable the chemotherapy to be delivered, and its toxins flushed out by the laxative.

Ms La Bella presented to a GP several days before her death, and as a result went to the Royal Adelaide Hospital, where a CT scan found what the coroner called “numerous rounded densities in the stomach being compatible with tablets with several dozen noted”.

Ms La Bella told a consultant physician that the tablets were Buscopan, Panadeine Forte and “analgesia from her mother,” but he was concerned that if the tablets were analgesia, it would be “highly unlikely” that she would still be talking to the physician 24 hours after the scan, the coroner said. He planned to investigate further – and was unaware that Ms La Bella had been claiming she had terminal cancer.

Indeed Ms La Bella went to “extraordinary lengths to be secretive about her health,” the coroner said.

An expert witness, a consultant psychiatrist, told the inquest that Ms La Bella presented with a concurrence of an eating disorder, likely anorexia nervosa, and a “severe” presentation of factitious disorder such as Munchausen syndrome.

Pharmacy involvement

The coroner focused on testimony from two workers at the pharmacy where Ms La Bella and her husband bought the Dulcolax: a retail manager, and pharmacist Ms Tan.

The retail manager claimed that she spoke to Ms Tan on three occasions about whether she should sell Dulcolax to the La Bellas, on one occasion asking Ms Tan whether it was acceptable to sell Mr La Bella 10 to 15 boxes, and being told it was.

But the coroner said the retail manager was an “unimpressive” witness and that he believed the pharmacist’s testimony that the retail manager had not consulted Ms Tan about the laxative purchases at all.

“Ms Tan was well aware of the appropriate dosage and usage for Dulcolax as a medication,” the coroner noted.

“She noted that it should be used only in the short term unless there is a chronic issue with long-term opioid painkillers which cause constipation.

“She said that she had never been asked to approve an order for Dulcolax or any unscheduled drugs… She said that she had not been asked about bulk sales of Dulcolax and that she did not know Claudia La Bella, even by sight.

“She certainly was never asked about the sale of 15 to 20 boxes of 200 Dulcolax tablets.”

Such purchases would have rung alarm bells, Ms Tan testified, saying she was shocked when she found out the number of tablets the pharmacy had sold Ms La Bella.

“I find that Ms Tan had no knowledge of these sales,” the coroner noted. “Had she done so I am very confident that she would have made appropriate enquiries.”

Mr Johns made a number of recommendations, including that “Dulcolax and like medications be classed as pharmacist only medications, the safe use of which requires professional advice”.

“They should not be available for self-selection from pharmacy shelves or online stores and purchases should only be made following consultation with the pharmacist.

“In particular I draw this Finding to the attention of the Pharmacy Board of Australia, the Pharmacy Guild of Australia, the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine.”

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  1. JimT

    with this sort of addiction whether the medicine is made pharmacist only or prescription only it will only lead to pharmacy or doctor shopping, with no real way of monitoring what is prescribed (especially if it’s a private item) or sold in pharmacy. However if it became a monitored item as proposed with codeine combinations etc then that’s a real solution.

    • Peter Crothers

      Agree. I would go further and say that it has taken me 40 years to reluctantly come to the view that all scheduled medicines should by law be recordable (and therefore monitorable) and that many more medicines than at present should be scheduled. Beyond that, what we really need is a reliable system of unique patient identification (UPI). Campaigning against the Australia Card was one of the most short-sighted things Australian pharmacists ever did
      In my opinion.
      With 100% hindsight.

      • JimT

        UPI and blockchain technology should make it very easy and very secure

  2. Naomi

    The new layout of some pharmacies, with a checkout at the front, out of sight and earshot of the pharmacist, surely is responsible for the pharmacist being unaware of the unusual amount of sales of the laxatives. I really feel that our regulatory bodies have let our profession down by allowing the proliferation of this type of layout. Pharmacy design of the olden days used to give the pharmacist a basic overview of what was happening in the shop, which we were taught was important when I was studying (only 15 years ago). Working as the pharmacist in charge, I feel much more confident when I can hear conversations between pharmacy assistants and customers, and often have intervened when I felt it necessary. This case is so sad, there were opportunities missed at many levels.

    • JimT

      but it still does not stop the same thing happening at the next shop/surgery etc doesn’t matter how thorough the practitioner is….

  3. Karalyn Huxhagen

    When I originally wrote QCPP procedures laxatives was one area that I wrote in to our policies (and QCPP in general) that needed education to pharmacy staff as well as survelliance of sales. As has been highlighted this patient was secretive and clever in hiding her disorder . My opinion is that you start with educating pharmacy staff about products that require extra vigilance and awareness. If they undertsand the possibility of abuse than they can be your eyes and ears. For example Glucodin being used for cutting ICE or similar illicit drugs, clear eyes being injected, deodorants being chromed, Loperamide used to heighten response to opioids . There are many products that can cause death on our shelves. Training and education of all levels of pharmacy assistant increases your eyes and ears.

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