Responsibility on GP, not pharmacists

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Acting chief pharmacist criticises GP’s lack of sufficient assessment of a “high-risk and potentially dangerous” prescribing regimen to a woman who died

A GP should have exercised more caution in prescribing to a 46-year-old Tasmanian woman who died from mixed prescription drug toxicity, a coroner has found.

The woman, named Michelle, was under the care of her regular GP, Dr Q, who prescribed her medication for pain and various medical conditions.

Michelle left Tasmania in early 2018 to spend most of the year in Queensland, then returned to Tasmania that December.

During that month, she visited Dr Q to refill her prescriptions. She presented him with a handwritten list of the medications that she required, which she stated had been prescribed to her in Queensland and which she had run out of in the road trip back to Tasmania.

The prescriptions issued by Dr Q included oxycodone (reduced dose), temazepam, Valium, Panadeine Forte, tramadol and Lyrica.

Less than two weeks later, the woman was found deceased by loved ones.

A forensic pathologist noted that multiple prescription drugs were detected in her blood were at elevated concentrations, complicated by her lung disease which increased risk her of death due to drug-induced central nervous system depression.

Tasmania’s Acting Chief Pharmacist Sam Halliday provided a report to the Hobart Coroners Court on behalf of the Pharmaceutical Services Branch (PSB).

He noted that Michelle’s medication included a combination of sedating and psychotropic medications including multiple opioid analgesics, multiple benzodiazepines, pregabalin, high-dose amitriptyline, sumatriptan and metoclopramide.

This was considered a “high-risk and potentially dangerous regimen” in the absence of clinical risk mitigation strategies, he said.

After reviewing the evidence, Mr Halliday concluded that Dr Q did not undertake a sufficient risk-benefit assessment of the prescribing regimen before issuing scripts to the patient in December 2018, just before her death.

Further consideration may have caused Dr Q to require staged supply to the patient, he said.

Mr Halliday made inquiries with Queensland’s Department of Health and confirmed that Michelle had never been dispensed S8 medicines in Queensland.

He noted that if Dr Q had sought and received advice that the patient had not been prescribed any S8 substances in Queensland, instead of relying on the handwritten letter, it is likely he would not have prescribed OxyContin at this time and may have been more circumspect in prescribing the other medications in the high-risk combinations.

He also concluded that Dr Q had an “unrealistic expectation” of the role of the PSB in assessing a patient’s prescribing regimen.

“He appeared to assume that where an authority had been granted by a PSB delegate, the doctor may take less responsibility for consideration of contemporary medical evidence, current practice guidelines or in the conduct of a full risk-benefit assessment,” said the Acting Chief Pharmacist.

Mr Halliday added that “PSB pharmacists are not registered doctors nor in a position to directly assess and manage patient care. It is the general practitioner who carries the primary responsibility for patient care”.

In his defence, Dr Q stated that he had taken the step of discussing the prescription regime with the pharmacist and made preliminary phone contact with the PSB to check if there were any barriers to prescribing from its point of view.

Dr Q said that both he and the pharmacist were reassured by the PSB that there were no prescribing barriers.

However he did not dispute the comments made by the Acting Chief Pharmacist.

Dr Q also emphasised in his reports that he had known the patient since she was a child, and that she did not display any signs of drug seeking behaviours, intoxication or emotional issues at the time that she presented to him.

Tasmanian Coroner Olivia McTaggart concluded that Dr Q should have exercised more caution, knowing he had not treated the patient for the past 12 months.

However she also acknowledged that the patient was a person at risk of an overdose by the manner in which she both hoarded medication and did not take medication as directed.

Coroner McTaggart accepted that Dr Q did his best at the time to attempt to prescribing safely to his long-term patient, however “time pressures and a desire to assist her symptoms” resulted in a decision to prescribe without taking all of the steps required to ensure risk was minimised.

She also observed that the patient was “well aware” of the requirement to take her numerous medications as prescribed, and of the risk of toxicity in the event that she did not do so, noting also her responsibility towards her own safety.

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