Over 100 regulatory breaches uncovered

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A coroner has criticised the excessive supply of S8s and codeine that led to a woman’s death

The death of a Tasmanian woman from mixed drug toxicity has been investigated by the state coroner.

Melissa Mary Spencer, 54, died from an accidental overdose of prescription drugs in June 2019.

Ms Spencer’s medical records indicated that, at about the time of her death, she was using or at least prescribed Kapanol, Mersyndol, temazepam, Nexium, Prozac and Sotacor.

Investigations after her death indicated that she was also taking other medications.

A significant array of drugs were present in samples taken during autopsy. These included morphine, codeine, doxylamine, paracetamol, nitrazepam, pregabalin, varenicline and erythromycin.

Analysis found that both morphine and doxylamine were present in elevated concentrations. These, combined with codeine and nitrazepam, are all central nervous system (CNS) depressants.

CNS depression may result in symptoms such as feeling sleepy and uncoordinated, staggering, blurred vision, impaired thinking, slurred speech, slow reflexes and breathing, decreased heart rate, and loss of consciousness possibly leading to coma or death, according to evidence from the Forensic Science Service Tasmania.

Morphine was detected at an elevated level of 0.88 mg/L. However Tasmanian Coroner Simon Cooper noted a degree of caution was needed in determining the significance of this elevated level, since tolerance to morphine develops over time, particularly in relation to long-term users of the drug.

There was no evidence Ms Spencer took the overdose of drugs with the express intention of ending her own life.

A report provided for the investigation by the Tasmanian Department of Health’s Pharmaceutical Services Branch (PSB), which keeps a record of all prescribing on its database, indicated that since 2009 there had been 112 breaches of the Poisons Act 1971 in relation to the supply of relevant substances to Ms Spencer.

Thirty-seven of these were “technical in nature” and found not to “meaningfully impact on patient safety at the time of supply”.

Fourteen breaches related to prescribers not holding authorities to prescribe narcotics and 20 breaches related to excessive and early supply of Schedule 8 substances to Ms Spencer.

Ms Spencer was first declared by a medical practitioner in Tasmania to be drug dependent in February 1996. Authorities were required to dispense S8 substances including morphine to her after that time.

The remaining 41 breaches related to the supply of codeine to Ms Spencer.

Coroner Cooper said it was “quite apparent, from the evidence, that in this case, there has been a significant departure from the standards required by the legislation which governs the prescription of Schedule 8 drugs”.

“Even the so-called ‘technical’ breaches are a matter of concern. The regulatory system in place is designed to provide a regime which enables the safest possible therapeutic use of narcotic substances by members of the community, recognising that those narcotic substances can have death as a side-effect,” he said.

“The breaches with respect to the supply of codeine also are a matter of concern, particularly given that it was being provided at a time when morphine was also being prescribed,” the coroner added.

Coroner Cooper was satisfied that virtually all of the breaches related to the prescribing practices of Ms Spencer’s regular GP.

He commented that the system established by the Poisons Act 1971 to regulate the prescribing, dispensing and use of narcotic and similar drugs is important to ensure their safe use.

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  1. Tamer Ahmed

    I don’t know but it appears that every coroner report praises the effort of the actions of every doctor involved in a patient’s death and over critisising the actions of every pharmacist involved ? As if these medications prescribe themselves or the doctors involved were oblivious to what are they doing ?

    • Jarrod McMaugh

      “Coroner Cooper was satisfied that virtually all of the breaches related to the prescribing practices of Ms Spencer’s regular GP.”

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