RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Glenn Hay, Coroner, have investigated the death of

Ellicia Stevie Nauta

WITHOUT HOLDING AN INQUEST

I have decided not to hold a public inquest hearing into her death because my investigations have sufficiently disclosed the identity of the deceased person, the time, place, cause of death, relevant circumstances concerning how the death occurred and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act 1999.  I do not consider that the holding of a public inquest hearing would elicit any information further to that disclosed by the investigations already conducted by me.

I FIND THAT:-

(a) Ellicia Stevie Nauta (Ms Nauta) died on 13 August 2008 in the public toilets behind the Moonah Bar and Café in Moonah.

(b) Ms Nauta was born in Port Headland, Western Australia on 24 December 1979 and was aged 28 years.  She was unmarried and unemployed.

(c) Ms Nauta died of a drug overdose (methadone, oxycodone, alprazolam, diazepam and nordiazepam).  Contributing factors were foreign body damage of the lungs due to intravenous drug injection of inappropriate drugs and active chronic hepatitis. 

RELEVANT BACKGROUND MATERIAL:-

Ms Nauta moved to Tasmania with her family in 1986.  She had troublesome teenage years. At age 17 she commenced using illicit recreational drugs and she continued to abuse drugs until her death.  In August 2002 she was commenced on the methadone program.  Between 2002 and 2005 she intermittently participated in the program.  Between 2006 and June 2007 there are no records of her receiving prescribed methadone or other opioid medication.  However, in August 2006 there is a record she voluntarily left the Detox unit at Alcohol and Drugs Services (ADS) against advice and before her use of benzodiazepines could be addressed.

In August 2006, the Chief Pharmacist at the Pharmaceutical Services Branch of the Department of Health and Human Services (PSB) contacted her medical practitioner, Dr Barnes and also alerted all general practitioners that they were not to prescribe drugs of dependence including alprazolam (Xanax) to Ms Nauta as she was still under an authority issued to ADS.

In June 2007 Ms Nauta re-enrolled in the methadone program under Dr Lawrence at the Taroona Family Medical Centre, an accredited prescriber for opioid pharmacotherapy such as methadone.  In October 2007 Dr Lawrence was advised by the Chief Pharmacist and also the Director of ADS that Ms Nauta was possibly shopping for benzodiazepines and those take-away doses of methadone must be stopped for her own safety, if she was also taking benzodiazepines.

In late 2007 ADS provided general instructions to medical practitioners not to prescribe alprazolam to pharmacotherapy patients unless approved by the clinical director of ADS.

Monthly monitoring of pharmacy reports by PSB in November 2007 alerted that body that Ms Nauta was receiving alprazolam (Xanax) as prescribed by another general practitioner, Dr Salter.  Dr Salter, Dr Lawrence and also Dr Fernando, who was taking over Dr Lawrence’s practice, were advised not to make such prescriptions and it was stressed they were not to provide take-away doses of methadone to her and they should not prescribe benzodiazepines to her.

In February 2008 Dr Fernando, who was accredited to prescribe methadone to Ms Nauta, was advised by letter from the Chief Pharmacist that further monitoring had detected a benzodiazepine in the form of alprazolam (Xanax) was being prescribed to Ms Nauta with a request to again cease any such prescribing.

It was not until a letter dated and signed 28 February 2008, when Drs Lawrence and Fernando wrote to Ms Nauta informing her that they were no longer permitted to prescribe Xanax to her and that over the ensuing three weeks her dosages would be gradually reduced to cessation.  Dr Fernando was of the opinion that as Ms Nauta was long term benzodiazepine dependent, she had an obligation to gradually reduce the medication rather than cease it immediately.  As a result Dr Fernando reports “I commenced with Antenex 5mg, tds which was reduced to 5mg bd a week later.  The plan was to cease Antenex completely within 2 to 3 weeks”.

It is to be noted that my advice is that Antenex is also a benzodiazepine.

From all available evidence it would seem that until 12 March 2008, Dr Fernando continued to prescribe Xanax and from that date Ms Nauta continued to source alprazolam (Xanax) illegally, however she continued to receive Antenex from her general practitioner following that date.

Contrary to the reported, commencement of Antenex at 5mg doses as noted above, from medical records of Ms Nauta it is clear that Dr Fernando first prescribed Antenex 2 mg twice daily on 12 March 2008, sufficient to last Ms Nauta for 25 days.  On the same day she was also prescribed Antenex 2mg 4 times per day, sufficient for a further 13 days.  On 12 March Ms Nauta reported to Dr Fernando that she was ‘having major panic attacks’.  On this date Dr Fernando completed a ‘mental health questionnaire’ and Ms Nauta ‘came across very depressed 45/50’.  Dr Fernando was of the opinion that Ms Nauta displayed signs and symptoms of borderline personality disorder and considered that in all of the circumstances Ms Nauta was difficult to manage.  Antenex was prescribed to ‘assist Ms Nauta with anxiety/panic attacks’.

I accept the opinion of Dr Fernando that at the time she commenced to prescribe Antenex she was aware Ms Nauta was a long-term benzodiazepine dependent person and according she had an obligation to gradually reduce the medication rather than cease it immediately.

On 31 March she was again prescribed Antenex 2mg 4 times per day, sufficient to last 13 days.

On 23 April she was again prescribed Antenex 2mg 4 times per day, sufficient to last 13 days.  During this consultation Ms Nauta reported concerns relating to mental health issues including low self-esteem, vulnerability and feeling very insecure.

On 20 June she was again prescribed Antenex 2mg 4 times per day, sufficient to last 13 days. On this consultation Dr Fernando noticed injection marks on Ms Nauta who reported she was getting Xanax from the streets and injecting.  Ms Nauta asked for an increase in the Antenex dosage but this was refused.

On 10 July 2009 Dr Fernando did increase the dosage to 5 mg twice daily, sufficient to last 25 days. In a written report to me dated 2 December 2011, Dr Fernando stated that the reason for the increase in dose was because ‘she was having difficulty coping’. However the patient files/progress notes for Ms Nauta make no reference to this or any other concerns on this date.  Further, that report from Dr Fernando states that ‘on July 10 the Antenex was reduced to 5mg 3 times a day’,  however the patient records do not corroborate this.

Again on 31 July Ms Nauta was prescribed 5mg twice daily doses, sufficient to last 25 days.  On this day she reported she was continuously obtaining Xanax from the streets.

Patient records disclose that daily 60mg doses of methadone were reduced to 55mg on 23 April 2008 and then to 52.5mg on 20 June 2008.

It must also be noted that in Dr Fernando’s initial report to me date 19 April 2010, she made significant errors in the dates various drugs were prescribed and these errors took some time to sort out and correct, leading to a delay in the finalisation of this inquest.
 
To summarise, from the evidence available to me it is clear that Dr Lawrence and/or Dr Fernando failed to take notice of the November 2007 notice to not prescribe alprazolam and only took steps after receipt of a second letter in February 2008.  Dr Fernando did not cease to prescribe alprazolam until March 2008 and then commenced Ms Nauta on diazepam (Antenex) which is also a benzodiazepine.  I accept that this latter prescription was in all the circumstances a reasonable step to take in the appropriate medical care of Ms Nauta.  However, Dr Fernando continued the prescription of Antenex well beyond the ‘2 to 3 weeks’ reduction plan, increased the dosage and continued to prescribe that medication to the date of death.

Contrary to the advice and warnings given by PSB and ADS, monthly methadone dosing records received by PBS show that Ms Nauta continued to receive three take-away doses each week as authorised by either Dr Fernando or Dr Lawrence.  In addition, Ms Nauta accessed daily doses from authorised issuing pharmacies on the days for which take-away doses were not provided.

I accept the evidence of the Chief Pharmacist that it would have been clinically wise to cease methadone take-away doses whilst Ms Nauta was reducing her benzodiazepines as that process would have made her unstable.

On 8 August 2008 Ms Nauta received three take-away doses of methadone for 9, 10 and 11 August 2008.

CIRCUMSTANCES SURROUNDING DEATH: -

In the morning of 13 August 2008 Ms Nauta attended a North Hobart pharmacy and took her non take-away dose of methadone.  During that early afternoon she met an acquaintance, Bobbie Jo Baillie (Mr Baillie) and requested him to source Xanax for her.  Mr Baillie reports that Ms Nauta appeared to be ‘stoned’ at that time.  They caught a bus to Moonah.  Mr Baillie had made contact with two persons who sell illicit drugs and they met them at Moonah.  Mr Baillie obtained 98 Xanax tablets and Ms Nauta purchased 58 of those tablets from Mr Baillie.  She gave Mr Baillie a sum of cash and also gave her newly acquired mobile telephone to him in exchange for the drug.

At about 3.03pm Ms Nauta and Mr Baillie went into a cubicle together at the public toilets behind the Moonah Bar and Cafe.  Ms Nauta mixed approximately 24 of the Xanax tablets with water and twice injected this solution into her groin.  There is no evidence any other person was involved in injecting the drug into her body. Ms Nauta almost immediately fell into drug-induced unconsciousness. 

Mr Baillie unsuccessfully attempted to wake Ms Nauta.  Fearing that Ms Nauta had overdosed, he left the cubicle and between 4.05pm and 4.10pm he caught a bus to Hobart.  It is his evidence that Ms Nauta was still breathing at the time he left her.

Whilst on the bus Mr Baillie reported Ms Nauta’s condition to the bus driver and at 4.14pm the bus driver radioed his base with a request police be notified.  After the bus arrived in Hobart at 4.25pm, Mr Baillie telephoned the Ambulance Tasmania on 000 at 4.39pm, seeking assistance for Ms Nauta. 

At or soon after 4.20pm Ms Nauta was located by a member of the public in the toilets and assistance was called for.  I accept the evidence of that witness that Ms Nauta was not breathing and appeared deceased at that time. Ambulance Tasmania was notified at 4.31pm and attended at about 4.40pm.

Resuscitation attempts were undertaken by Ambulance Tasmania personnel without success.  A medical assessment determined that Ms Nauta was deceased. 

A post mortem examination was carried out by Forensic Pathologist, Doctor George Kelsall.  Dr Kelsall determined the cause of death to be a drug overdose (methadone, oxycodone, alprazolam, diazepam and nordiazepam).  Dr Kelsall recorded that Ms Nauta had ‘enlarged congested lungs with extensive foreign body reaction due to injected impurities as seen in habitual intravenous drug users’, and ‘a low grade active chronic hepatitis, consistent with chronic intravenous drug use’.   I accept and rely upon that opinion.

Toxicology results from a post mortem blood sample revealed ‘potential methadone/mixed drug toxicity’.  Dr Kelsall states that the drugs identified in the post mortem blood ‘cause respiratory depression and are all capable of enhancing the effects of one another, in this case considered sufficient to be fatal’.  I accept and rely upon that opinion.

FINDINGS, RECOMMENDATIONS AND COMMENTS:-

I am satisfied that a thorough, detailed and extensive investigation into the death of Ms Nauta was completed, including investigations into the information provided by Mr Baillie and together with the prescription of drugs/medication to her.  Investigating police satisfied themselves that there were no suspicious circumstances surrounding her death.  Despite some unusual aspects in the available evidence I accept and adopt those opinions.

It is clear Ms Nauta had a long history of drug abuse and was heavily involved in the drug culture.  I am also satisfied that she died on the 13 August 2008 somewhere between about 3pm and 4.30pm in the public toilets behind the Moonah Bar and Café, Moonah from an unintentional drug overdose (methadone, oxycodone, alprazolam, diazepam and nordiazepam).  Contributing factors were foreign body damage of the lungs due to intravenous drug injection and active chronic hepatitis.

She had been treated by ADS for opioid and benzodiazepine dependence.  There is sufficient evidence to find that for some time prior to her death she in all probability often sold her take-away doses of methadone or alternatively was intimidated to give them away or had them stolen from her.  From time to time she became ill from not taking her prescribed methadone and was then buying or otherwise obtaining and injecting her drug of personal choice, alprazolam.

In my view, her participation in the methadone program may well have indirectly contributed to her death in that take-away doses of methadone was an asset in her possession and more likely than not, she from time to time, sold it to purchase other drugs of choice including the Xanax purchased by her on the date of her death.

Also of significant concern is the fact that her relevant pharmacotherapy accredited general practitioners (Drs Lawrence and Fernando) continued to supply Ms Nauta with take-away doses of methadone when they had been advised on at least two occasions by the PSB to stop doing so, in the interests of the health and safety of Ms Nauta.  From her medical history it was clear she was a difficult patient and this should have been realised by her medical advisers at an early stage with a referral to a drug addiction specialist for support and guidance upon her proper treatment and this should have been abundantly clear to Dr Fernando at least following receipt of the directions not to dispense take-away doses of methadone or to prescribe benzodiazepines in late 2007 and early 2008.

However, I note that Ms Nauta had taken a 52.5mg dose of methadone at a pharmacy on the morning of her death and I am unable to find that the take-away doses of methadone had any direct involvement in her death.  Toxicology tests disclosed that the level of methadone in her system was within the therapeutic range.

It is also of concern to me that Dr Fernando prescribed to Ms Nauta a benzodiazepine for anxiety/panic attacks contrary to the advice of PSB and ADS and contrary to her own plan to cease that medication entirely within 2 to 3 weeks and in fact increased that dosage over 3 months after the cessation of that initial 2 to 3 week plan.  There is clear evidence from information gathered during the course of my investigation that generally there are good and sensible reasons why benzodiazepines should not be prescribed when a patient is on a methadone program and further, that the prescribing of benzodiazepines has little if any role in appropriate treatment of ‘panic attacks’ and its use in what is commonly described as ‘anxiety’ conditions should be for a very short term.  I accept that individual cases may differ.

While there is no evidence to find this prescription of benzodiazepine lead to or directly contributed to the death of Ms Nauta, given her long history of drug abuse, her history of doctor-shopping for drugs, her history of sale or barter of drugs and the contra-indication of mixing methadone with benzodiazepines, I could not rule out its connection with her status and condition at the time of her death.

The notices by PSB were clearly ignored in this case and I have not been provided with any plausible reason for doing so.  If that attitude was universal amongst medical practitioners then it would make worthless the role of the Chief Pharmacist in keeping a watch over patients and those who clinically look after them.  It would also seriously devalue the newly introduced real-time notification procedures for the prescription of all Schedule 8 drugs in Tasmania. 

Further, from information available to me during my investigation it would seem that the prescribing of take-away doses of methadone contrary to advice or without close assessment of each patient; or a lack of understanding of the risks to the patient; or the prescribing of two or more incompatible drugs; or the failure to recognise optional treatment; or a lack of understanding of addictive behaviour and possible associated mental health issues - is not an uncommon systems failure within Australia.  I would recommend and urge medical schools to ensure appropriate training of new medical practitioners in those areas and the continuing and regular education/professional development of all such practitioners engaged in these complex areas, including skills in the objective assessment of subjective information provided by patients. 

As I understand it, accreditation of medical practitioners to prescribe opioids can be removed by ADS and/or PSB or under the provisions of the Poisons Act for non-compliance with best practice or if the prescribing of pharmaceuticals is placing patients at risk.  I recommend a firmer system of enforcement of those obligations in appropriate cases.

It is not the first time similar issues to those raised by me in and about the cause of this death have been commented upon by Tasmanian Coroners.  I adopt and repeat the following recommendations of Coroner Chandler in the inquest into the death of Ami Pepper which occurred on 28 April 2009:

The foregoing leads me to recommend that prescribing clinicians, when considering whether a patient should be authorised to use “takeaways” as part of a methadone or buprenorphine programme, should have regard to the patient’s personal and domestic circumstances and in particular whether the patient resides with a person who is mentally unstable and at risk with respect to drug misuse.  In these circumstances the patient should not be authorised to use “takeaways” unless the clinician can be satisfied that the drug will be safely and securely stored so that the co-resident is unable to gain access to it.  An esky is not a suitably secure place.  It is my further recommendation that any decision made to authorise the use of “takeaways” be continuously reviewed by clinical assessment and by consideration of information provided by the patient and by other health professionals regarding the patient’s living and social circumstances.  Assessment of clinical stability and of any patient and public safety issues should form a routine part of clinical assessment each time the patient is reviewed by his/her prescriber.  Such review will enable the prescribing physician to consider his/her assessment of the patient’s need for “takeaway” doses in the light of any change in the patient’s circumstances including his/her domestic arrangements. 

For all of the above reasons and my concerns I propose forwarding a copy of my findings to the Chief Pharmacist; the Medical Council; the Australian Health Practitioner Registration Agency and the Dean of the Medical School at UTAS, for their consideration and further investigation, if considered necessary.

It is also important to bring to the attention of the community that in 2010, of the 14,679 medical registrars under tuition in Australia for entry into differing specialties, only 11 of them were being trained in the specialty of addiction medicine.  In this ever burgeoning problem area, that must be of considerable concern to our community.
 
My investigations also lead me to a strong conclusion that experienced long-term users of prescribed opioids are adept at so-called ‘doctor shopping’ to obtain multiple prescriptions and then selling part or all of their take-away methadone doses to illicitly fund their preferred drug such as benzodiazepines.  They can also be adept at demanding the prescription of a particular drug and I can accept that from time to time with the constraints of the Medicare system and the lack of time available to medical practitioners in some cases, they may prescribe according to the wish of the patient rather than by full objective assessment of needs.  However, in my view that does not absolve them from their responsibility of ensuring proper treatment and prescription in the best interests of the patient.

In April 2010 when handing down a finding in a death of a person who was clearly ‘doctor shopping’ for multiple drugs, I recommended the acceleration of a proposal for a national and centralised register accessible by medical practitioners and pharmacists, to provide data which would undoubtedly minimise this practice to the benefit of the patient and the community.

So it is on a more positive note and very pleasing to discover that Tasmania is now leading the country in the implementation of real-time notification of the prescription of all Schedule 8 drugs in Tasmania.  This innovative system has been developed over the past two years or so and has now captured about 95% of pharmacies dispensing reportable drugs such as Schedule 8 drugs including opioids and the benzodiazepine alprazolam.  A new system is now being rolled out to community GP’s which will allow them to be able to connect to a special data base.  This data base will give them access to appropriate information to support their decision to prescribe opioids.  The information will relate only to the patient being treated and not third party information. 

In my view, such prescribers need this support at the time of prescribing drugs of dependence especially if the patient is not known to them.  Access to this data will be available in real-time once GP’s are connected via their desk-top computers.  It is my recommendation that any medical practitioner prescribing opioids and in particular any practitioner accredited as a prescriber of opioid pharmacotherapy must follow standard good clinical practice and check that data base before prescribing.  Alternatively, if they are unable to access the data base they will have the option of contacting PSB direct.

The challenge will now be for other States and the Commonwealth to roll-out this system to overcome the problem of interstate doctor-shopping or dispensing of Schedule 8 type drugs.

In addition to this very useful data base, such medical practitioners must also in my view, assess that information in the light of evidence-based practice to understand all of the potential risks to the patient in prescribing, or not, such medication.  In my view, while patient preference for the prescription of a particular drug is a relevant and an important element of evidence-based clinical practice, it should not override the evidence-based expert opinion of the medical practitioner as to the most appropriate therapeutic model for each patient and the prescription or not of any particular drug.

Mr Baillie was charged with the offence of selling a prescribed drug to Ms Nauta, for which he pleaded guilty and received a 3 month term of imprisonment commencing on 24 September 2009. 

I have also considered whether Mr Baillie had a legal duty to provide assistance to Ms Nauta and if that assistance was given. 

Section 144 of the Criminal Code 1924 states:

“It is the duty of every person having charge of another, who is unable by reason of age, sickness, unsoundness of mind, detention, or any other cause to withdraw himself such charge, and who is unable to provide himself with the necessaries of life, to provide such necessaries for that person.”

Section 144 liability will only arise where a person has charge of another.  I find that Mr Baillie did not have charge of Ms Nauta in the context of section 144 and find he was not in breach of it.  Nevertheless he still performed some duties referred to in section 144 by seeking assistance from the bus driver and further calling 000 to seek ambulance assistance once in Hobart.

However, there was approximately over an hour between the time Mr Baillie and Ms Nauta entered the toilets and the time the bus driver acted upon Mr Baillie’s information and called emergency services.  While Mr Baillie may not have had a strict legal duty to Ms Nauta, a more appropriate course of action was for him to immediately bring her situation to the attention of members of the public or emergency services at or near the location, so that medical treatment could have been commenced as soon as possible.  Instead he walked to Main Road Moonah, waited for a bus, caught the bus and informed the driver only after the bus had driven away from the area with no follow-up until the bus arrived in Hobart around half and hour later.  It is most likely that Ms Nauta was left undiscovered in a public toilet for many valuable minutes before being found and the emergency services called to attend. I cannot say that Mr Baillie’s lack of early notification contributed to her death, but on the other hand it cannot be ruled out.

I conclude by conveying my sincere condolences to Ms Nauta’s family.

DATED:- 16 March 2012 at Hobart in the State of Tasmania.

 

Glenn Hay
CORONER