RECORD OF INVESTIGATION INTO DEATH (WITHOUT HOLDING AN INQUEST)
Coroners Act 1995
Coroners Regulations 1996
I, Stephen Raymond Carey, Coroner, having investigated the death of:
Sandra Winidred HAY
WITHOUT HOLDING AN INQUEST
a) The deceased is Sandra Winifred Hay (Ms Hay) who died at a precise time unable to be determined but subsequent to 8pm on 8 February 2009 and before 1pm on 9 February 2009 at 75 Bally Park Road, Dodges Ferry.
b) Ms Hay was born on 16 February 1949 and was aged 59 years.
c) Ms Hay was a single person who was employed as a registered nurse.
d) Ms Hay died as a result of the combined effects of mixed drug toxicity and aspiration pneumonia.
Circumstances Surrounding the Death:
Ms Hay first commenced receiving opioid based medication for the treatment of chronic pain relating to arthritis and spondylitis in 2004. Her treating general practitioner, Dr Mercado, reports that the chronic pain suffered by Ms Hay was treated with strong analgesics and physeptone. This medication was prescribed with the support of her treating specialist rheumatologist, Dr Cooley, and they controlled her symptoms to a moderate degree and allowed Ms Hay to continue to work as a nurse. Although Ms Hay had a history of depressive episodes during the period from the late 1980s to early 1990s, her family report that there were no indications that she suffered depression in the latter years of her life. Ms Hay is reported to have fully engaged herself in family events and actively participated in the lives of her children and grandchildren. Ms Hay’s family report that she would travel to Launceston regularly to see her grandchildren that lived there and was excited about her unborn grandchild that her daughter, Petalynne, was carrying at the time of her death. In the lead up to Ms Hay’s death she did not display any signs of depression and this is supported by her treating general practitioner, Dr Mercado, who noted that depression was once a significant issue but this had been stable over more recent times. He noted that the pain suffered by Ms Hay did at times “get her down” but there was never any indication that she may have been suicidal.
In the 12 months leading up to her death, Ms Hay’s family had become increasingly concerned for her well-being as they observed her struggling to cope with the pain she was suffering and the amount of time that she tended to sleep. Although Ms Hay continued to work, apparently her need for sleep increased to the point where she would return from work and then go to bed, getting up to have a small meal and then returning to her bed.
Ms Hay’s health is reported to have deteriorated in the weeks leading up to her death. In these weeks she suffered considerably from constipation for which she could get little relief. Family members became increasingly concerned due to the pain she was in and her constant need for sleep. On 4 February 2009, Ms Hay’s daughter Petalynne took her to the Department of Emergency Medicine at the Royal Hobart Hospital as she was concerned for her well-being. At this time Ms Hay was described as having yellow skin, was vague and incoherent. At the Emergency Department Ms Hay was assessed by Dr Michelle Bowen who took a history that there had been a three day history of colicky abdominal pains, anorexia and nausea on the background of eight days since Ms Hay’s previous bowel movement. Ms Hay reported having tried laxatives the previous day with no effect. On examination her observations were unremarkable and remained stable throughout her stay. Of note however was an obvious fullness following the descending and transverse colon and x-rays showed significant fecal loading but with no obvious obstruction. Ms Hay was treated with analgesia and laxatives for probable constipation secondary to long-term opiates and anti-depressants. Ms Hay was managed in the Emergency Department overnight and her bowels opened with subsequent relief of pain. She was discharged at 8.30 on 4 February with ongoing constipation management and advice to follow up with her general practitioner.
On Friday 6 February she saw Dr Mercado complaining of feeling weak and tired and reported having spent a night in hospital under observation for constipation. He says that he discussed this complaint of constipation with Ms Hay and advised her to increase her dosage of Movicol from three sachets a day to six to eight sachets a day which was the recommended dose for fecal impaction. Of note is that the blood tests conducted whilst Ms Hay was in the Emergency Department did not indicate that she was jaundiced.
On Saturday 7 February 2009 her family report that Ms Hay appeared very ill, her skin was yellow and her behaviour was very vague and drowsy as if she was “half asleep”. Family report that she was unable to engage in normal conversation and she appeared very confused. She spent most of that day in bed. During the day on 8 February 2009 she again slept most of the day. However that evening she appeared to have become somewhat better, she had awoken in the evening and requested a toasted sandwich and milkshake. She stated to family members that night that she was keen to return to Dr Mercado, and indicated she was disappointed that the following day was a public holiday and that she would not be able to make an appointment for the following day. Ms Hay returned to her bed that evening at about 8pm. The next day Ms Hay's son, Stephen, decided to check on her well-being at approximately 1pm. He notes that it was not unusual for his mother not to have awoken before this time as she would on some occasions have difficulty sleeping during the night. He went into his mother’s bedroom and she was lying in bed. He was immediately concerned by her appearance and she was cold to touch. He immediately contacted his sister, Petalynne, and also the emergency services, with an ambulance arriving at 1.15pm. Following examination by the ambulance officers and an unsuccessful attempt to intubate Ms Hay no further resuscitation endeavours were pursued. Police were contacted and arrived shortly thereafter and commenced an investigation which disclosed no suspicious circumstances. An autopsy was conducted by Dr Donald Ritchey which identified aspiration pneumonia (inflammation of the lung caused by aspiration of gastric contents). Toxicology testing revealed the presence of multiple prescription drugs in therapeutic and greater than therapeutic blood concentrations. He concluded:
“These findings are interpreted by me to suggest that the effect of multiple central nervous system depressant drugs acted to decrease Ms Hay’s level of consciousness sufficiently to prevent her from adequately protecting her airway allowing for aspiration of gastric contents producing pneumonia. The combined effects of aspiration pneumonia and CNS (central nervous system) depression from multiple drugs caused respiratory arrest followed by death.
In addition, there was small, remote (healed) pulmonary infarcts caused by pulmonary thromboemboli (PTE). These small PTE did not contribute to death and may or may not be related to her history of systemic lupus (SLE). I did not find evidence that SLE directly contributed to Ms Hay’s death.”
Given the role played by the medication prescribed to Ms Hay in her death and also the observations as to the apparent effects of this medication on their mother, the family raised concern during the investigation into her death as to the level and appropriateness of the medication regime.
The use of Schedule 8 opioid medication is recorded by Pharmaceutical Services Branch of the Department of Health and Human Services and specific authorisations are required in respect of the supply of such medication. The records show that Ms Hay first commenced receiving Schedule 8 opioids for the treatment of chronic pain relating to arthritis and spondylitis in 2004. Authorities for the issue for this medication were provided to Dr Mercado. Initially Ms Hay was treated with long acting oxycodone. In late 2004 the authority changed for the use of methadone tablets 10mg. In May 2006 the requested authority was for a return to oxycodone which was changed back to methadone in September 2006. The use of methadone was supported by Ms Hay’s specialist rheumatologist. The initial dose of methadone used was 10mg twice a day, however in early April 2008 Dr Mercado requested an the authority to increase this dose to 10mg three times a day. Ms Hay’s medical history and the prescription of medication was considered by Dr Anthony Bell, Clinical Professor of Medicine who provided a report to me. He notes that the decision by Dr Mercado on 6 February 2009 to increase the dosage of treatment for constipation was appropriate. He also notes that Ms Hay’s family described the symptoms of “spaced out, confusion and looked unwell” over the next few days following her attendance upon Dr Mercado. Ms Hay was noted to be sleepy, drowsy and tired and Dr Bell comments that these symptoms are fairly typical of drug influence, especially the variability of symptoms. He comments that:
“I believe that the case represents death by aspiration of gastric contents with a provoking factor of drug ingestion. Although the drug levels are not high the side effects are present. The fecal impaction relates to the opioid drugs. Nausea and vomiting are related to the sertraline. Ms Hay had a milkshake and sandwich the evening prior. The combination of drugs could certainly affect the conscious level and lead to a greater chance of aspiration. Poor gastrointestinal mobility is also a risk factor for aspiration.”
He also concludes that:
“The opioid use seems appropriate and stable. These drugs were initiated by a specialist rheumatologist and appear appropriate.
The combination of drugs appears appropriate.
Then sudden death due to aspiration is well recognised.
Ms Hay died on 9 February 2009 from a combined effects of drug ingestion and aspiration pneumonia. Aspiration is a common method of dying. The human body is well designed to prevent aspiration but swallowing and airway protection is easily disrupted especially by drugs that depress conscious state.”
I am satisfied based upon the investigation and the medical assessment conducted as to Ms Hay’s medical ailments and her treatment that there are no suspicious circumstances in relation to Ms Hay’s death. I also accept that her medication regime was appropriate and that she was taking her medication in accordance with the prescription instructions. This was a tragic event which apparently was a not uncommon event where people are using strong opioid medication. Tragically it appears that because of her medical condition and the level of pain suffered by Ms Hay she required strong analgesic medication, such medication increased the risk of suffering aspiration pneumonia which occurred in this case.
Before concluding I wish to convey my sincere condolences to the family of Ms Hay.
DATED: 23 August 2012 at Hobart in the State of Tasmania.
Stephen Raymond Carey