A coroner has emphasised the need for work towards real time monitoring to continue as a matter of urgency, in handing down findings on the death of a toddler
The Queensland boy died in 2013, while in the care of his grandparents, who were both “doctor shoppers” and took significant amounts of oxycodone, orally and intravenously.
Some time between 11am and 11.30am on Saturday, 24 August, the child’s grandfather found him in his bed. The little boy was non-responsive and cold to the touch.
He was pronounced dead at the scene.
The 20-month-old boy’s parents had separated by the time he was born, and he lived with his mother, as well as other regular occupants of the home who included his maternal grandparents, a maternal aunt and a family friend.
While his mother was his primary carer, it was not unusual for him to be left in the care of his maternal grandparents for several days at a time.
This was the case at the time of his death: he and his mother had recently returned home after a three-week holiday in Western Australia, and on the morning of Friday, 23 August, his mother went to visit friends, leaving her son in the care of the grandparents and aunt.
In non-inquest findings, Northern Coroner Nerida Wilson noted that the boy had a cold the day before he died, which gave him a runny nose and occasional cough, but he was in good spirits and none of the occupants of the house saw any symptoms that caused them concern that the illness was anything more than a cold.
He spent the day with his grandparents and then playing with his aunt and grandfather before going to bed later than usual, settling sometime between the hours of 11.30pm and 2.30am on Saturday morning.
The coroner said this was consistent with the mother’s statement that the boy had not readjusted to the usual time zone.
While the coroner said there were some discrepancies around how many times the boy was checked on the Saturday morning, she said she accepted his grandfather saw him around 8.30 that morning.
“The grandfather claimed that he gave the child a bottle of chocolate milk and left him lying on the bed and apparently in good health,” she noted.
“It was reportedly a common occurrence that the child would have a bottle during the morning then doze off.
“The grandmother says she observed the child asleep on his belly (that morning at an unspecified time), with his head on the pillow and the blanket over him with one arm resting on top of it. The child was reportedly giggling and dreaming. The grandmother says that at the time she left the home later that morning, the child was asleep in the bed.”
When the grandfather discovered the boy dead between 11am and 11.30am, he noticed he had a wet mouth and “did not look right”.
An ambulance was called, and the officers saw the grandfather performing CPR on the boy before taking over, but were unable to revive him.
The autopsy found no obvious injuries indicative of past abuse or neglect, though the child, the grandparents and the grandparents’ children were known to child and safety services.
It found no clear cause of death, though there was some lung infection with evidence of inhaled food material and inflammation of the lining of the voice box region.
However, on testing for drugs and poisons, oxycodone was found at a level of 3.6mg/kg in the boy’s blood, which as the coroner noted, was “a level which in adults would be within the reportedly lethal range”.
The drug was not detected in milk submitted for testing.
The cause of death was ultimately determined as lung infection on the background of oxycodone intoxication.
Coroner Wilson found that the boy ingested oxycodone by “means unknown” while in his grandparents’ care.
She noted that in the light of the police investigation and a Medicines Regulation and Quality Unit (MRQ) report, she accepted that both the maternal grandparents had a “known history of obtaining drugs of dependence, including oxycodone (in tablet form)”.
The grandparents were the only people in the household with relevant prescription drug histories.
The maternal grandmother had, in the past, been registered as a drug dependent person, though she was not registered at the time of the boy’s death. The grandfather had never been registered.
“Both grandparents were known to have a history of ‘doctor shopping’,” the coroner noted.
A Forensic Medical Officer attached to the Clinical Forensic Medical Unit (Qld) said that while it was not possible to conduct a backward extrapolation from the level of oxycodone in the boy’s blood, he confirmed that “the amount ingested to produce the serum level detected at autopsy was likely to have been extraordinarily high”.
In the month prior to the boy’s death, one doctor had prescribed oxycodone to the grandfather on nine separate occasions.
Four of those occasions involved scripts for 40mg doses and the remaining five occasions involved scripts for 80mg doses, with a total of 252 oxycodone tablets,” the coroner noted. “Those prescriptions were dispensed at pharmacies based in Cairns.”
In the same period, he prescribed oxycodone to the grandmother on 11 occasions – six involving scripts for 80mg doses, and five for 40mg doses, with a total of 308 tablets. These scripts were also dispensed at Cairns pharmacies.
In a 480-day period (including the month before the boy died), this doctor provided scripts to the grandfather for a total of 1209 x 40mg OxyContin tablets and 2158 x 80mg OxyContin tablets.
A statement from a Queensland Monitored Medicines Unit Investigation Officer found that while under this doctor’s care, the grandfather was averaging 800mg of OxyContin daily.
MMU records also indicate that in a 290-day period (also including the month before the child’s death), this doctor provided scripts to the grandmother for a total of 517 x 40mg OxyContin tablets and 868 x 80mg OxyContin tablets.
In a statement to the Coroner, the Investigation Officer deposed that the doctor was acting unlawfully by prescribing OxyContin to the grandmother, who had been registered as a drug dependent person in the past, for the period of 23 April 2013 to 10 November 2013 without their approval.
The child’s death occurred during this time period.
The medicine was primarily kept in a safe, which both grandparents had access to.
“The medication was generally left in its blister pack however some of it was transferred into a ‘days of the week’ tablet dispenser,” the coroner noted.
The grandfather sold some of the oxycodone to other people, and the drug was not always taken in the same room as the safe in which it was stored.
Both grandparents admitted taking the medication both orally and intravenously. However, they said they took “extreme care” to ensure this never happened in front of the children.
They both denied that they would ever have supplied oxycodone to their grandchild for any purpose, a statement supported by all other occupants of the household, including the boy’s mother.
The child was “much loved and there is nothing to suggest he had ever been administered oxycodone in the past to either pacify or medicate. He was generally of good health. There was no evidence of oxycodone in his bottle from that morning,” the coroner noted.
She found there was insufficient evidence as to how the oxycodone came to be in the child’s bloodstream.
In July 2014, the doctor’s endorsements for S8 and S4 drugs of dependency were cancelled by AHPRA. In September 2014, the Medical Board of Queensland found the doctor’s practice of the profession to be “unsatisfactory” and conditions were imposed on his registration.
Some conditions were later removed, but in February 2017 he was cautioned for failing to comply with a condition which remained in effect: not to prescribe an S8 controlled drug.
He was cautioned again in January 2018 for having prescribed an S4 restricted drug of dependency, despite a condition against this remaining in place. By this time, he had allowed his registration to lapse through non-renewal, though he was registered at the time he prescribed the S4.
In discussing the issue of real time prescription monitoring, Coroner Wilson highlighted the 2018 findings of a Coroners Court at Southport, in which Coroner McDougall delivered findings following an inquest into the deaths of four people.
Each of those deaths was found to have involved the misuse of opioid prescription medication.
She noted that these findings repeated recommendations that a real time prescription monitoring system be implemented “as a matter of urgency”.
She noted that Queensland Health advised her that work is in progress to have the system active by 2020, and that is also progressing work with regard to legislative reform within the State that will provide a basis for the real-time monitoring system.
She also noted that there has been “significant uptake” of the MMU’s state-wide telephone enquiry service for medical practitioners to access prescription history information, regulatory advice and support.
Coroner Wilson observed that steps are also being taken to provide education programs for prescribers, dispensers and consumers regarding the monitoring of certain substances.