Record of Investigation into Death
Coroners Act 1995
Coroners Rules 2006
Rule 11
I, Olivia McTaggart, Coroner, having investigated the death of
Chrystal Tina Reynolds
WITHOUT HOLDING AN INQUEST
Find :
(a) Chrystal Tina Reynolds died on 10 August 2007 at 5 Gordons Hill Road at Lindisfarne in Tasmania.
(b) Miss Reynolds was born in Hobart on 29 June 1987. She was not married and was unemployed at the time of her death.
(c) Miss Reynolds died as a result of combined drug (methadone, quetiapine and benzodiazepine) intoxication.
Background:
Miss Reynolds was born in Hobart. Until the age of 15 years she lived with her father, Grant Reynolds. Mr Reynolds had a long history of illicit drug use and dealings throughout his life. It appears from the evidence that Miss Reynolds began using drugs prior to leaving home.
In 2005, when she was aged 17 years, Miss Reynolds saw her general practitioner, Dr Richard Bourke. At that time she told Dr Bourke she was taking 6 Valium tablets and injecting 60-100mg of morphine intravenously on a daily basis, and had been doing so for three years. Whilst she may have exaggerated her drug use to Dr Bourke, all of the evidence obtained for the coronial investigation confirms that she used drugs heavily from a very young age. Miss Reynolds asked Dr Bourke to put her on the Methadone program; however due to her chaotic lifestyle this was declined.
Dr Bourke stated that Miss Reynolds saw doctors at his practice on many occasions until her death presenting with numerous social and psychological issues, housing and accommodation problems, drug withdrawal and drug injecting issues and relationship problems. She refused to accept assistance from the Alcohol and Drug Service.
Miss Reynolds had several prison admissions during 2006 and one in 2007. Her prison admissions were typified by drug withdrawal, emotional lability, drug seeking behaviour, variability in what she told carers and staff and episodes of self-harm. Doctors noted she was ‘very chemically orientated’.
Both Dr Bourke and prison doctor Dr Chris Wake listed Miss Reynolds’ diagnoses as follows: benzodiazepine addiction, opioid addiction since the age of 15 years, borderline personality disorder with recurrent self-harm episodes, chronic trauma syndrome, hepatitis C and B positive, recurrent urinary tract infection, chaotic lifestyle and recurrent situational crises.
Miss Reynolds met Mr Ky Bradley Pearsall in 2004. From that time until Miss Reynolds’ death they had been in an intermittent sexual relationship. Their relationship typically revolved around the use of cannabis and methadone or morphine. Mr Pearsall would often obtain morphine or methadone for Miss Reynolds, for which she would provide the money for purchase. Mr Pearsall lived in a van at the rear of his parents’ residence at 5 Gordons Hill Road, Lindisfarne. When with Mr Pearsall, Miss Reynolds would stay in the van also. She was not allowed into his parents’ house.
Mr Pearsall was on the methadone program, and was prescribed three "takeaway" doses of methadone per week. Each takeaway dose consisted of an 80ml bottle of methadone. Miss Reynolds and Mr Pearsall regularly injected morphine and methadone together, and smoked cannabis. Miss Reynolds also took Seroquel (quetiapine) tablets that she was prescribed. However, there is no doubt that she also obtained other substances, including benzodiazepines, illicitly.
Miss Reynolds had also been in an intermittent sexual relationship with Damien Balmforth since they met in 2005. Mr Balmforth resided with his parents in Risdon Vale, and his parents often gave Miss Reynolds support, both financially and by providing food and accommodation. In the months prior to her death Mr Balmforth stated that the relationship was simply that they were friends. He stated that Miss Reynolds would arrive unexpectedly at his residence and stay for a while before leaving. Mr Balmforth had been a user of morphine, and commenced on the methadone program at the end of 2006. According to Mr Balmforth, Miss Reynolds would use "anything she could get her hands on"; and she would "get them in any way she could; by stealing, befriending people and sleeping with them". Mr Balmforth also believed Miss Reynolds had been using cannabis, amphetamines, and temazepam.
Before her death, Mr Balmforth saw Miss Reynolds once every week or fortnight, with her usually staying over on a Sunday night or Monday. On the methadone program at that time Mr Balmforth received one takeaway dose of methadone per week. The ‘takeaway’ consisted of one 85mg bottle of methadone. Mr Balmforth has denied supplying Miss Reynolds with methadone. I am sceptical of this claim. Her pattern of behaviour of visiting him regularly is consistent with her knowledge that he would be in a supply of drugs. However, I am not able to determine the extent of supply, if any, by Mr Balmforth. In any event Mr Balmforth is not linked with the supply of any substance that caused her death.
Circumstances surrounding death:
On Monday 6 August 2007 Miss Reynolds stayed overnight at Mr Balmforth’s residence. On the following morning, Mr Balmforth’s mother, Nicolina Balmforth, took her to the Commonwealth Bank in Lindisfarne. Miss Reynolds withdrew money and wanted to give Mrs Balmforth $100.00, presumably to repay some money to her. Mrs Balmforth tried to accept less money, however Miss Reynolds insisted on giving her the whole amount. Mrs Balmforth then took Miss Reynolds to Mr Pearsall’s residence.
From 6 August 2007 until her death on 10 August 2007 Miss Reynolds stayed with Mr Pearsall in his van.
On 10 August 2007 Miss Reynolds had spent the day with Mr Pearsall. Both had been smoking cannabis and at about 10:30am or 11:00am had injected Mr Pearsall’s prescription of methadone. Mr Pearsall had two 80ml doses and he gave Miss Reynolds one 80ml dose. Miss Reynolds injected 50mls of the methadone into her arm. They had five cones each of cannabis after injecting the methadone. Mr Pearsall had been in the van until about 1:45pm when his parents took the phone in to him after he received a call. He came into the house just after this and told them he was going to have a sleep, and then returned to the van. At this time Miss Reynolds and Mr Pearsall each had another four cones prior to going to sleep.
About 3:45pm Mr Pearsall woke up in the van next to Miss Reynolds. He attempted to wake Miss Reynolds to ask whether she wanted another ‘cone’. Mr Pearsall was unable to wake Miss Reynolds. Upon noticing she was not breathing he ran into the house asking his parents to call an ambulance. Mr Pearsall then attempted to perform CPR on Miss Reynolds in the van while waiting for the ambulance, with ambulance personnel giving instruction by telephone.
At about 4.15pm Ambulance Tasmania arrived. Ambulance personnel determined Miss Reynolds was deceased.
Tasmania Police attended the scene and Miss Reynolds was taken to the Royal Hobart Hospital by mortuary ambulance. Police took possession of the following exhibits at the scene:
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1 x empty box of Valium (diazepam) tablets
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1 x bottle containing 8 x Metrogyl (antibiotic) tablets
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7 x Seroquel (Quetiapine) tablets
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Methadone labels
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2 bags containing needles and assorted drug-related injecting items
A post-mortem examination was conducted by Forensic Pathologist, Dr Christopher Lawrence. Subsequently Dr Lawrence had the benefit of toxicology results. He determined the cause of Miss Reynolds’ death to be combined drug (methadone, quetiapine and benzodiazepine) intoxication. At autopsy Dr Lawrence noted observable changes consistent with recent intravenous drug use. He stated that there was nothing else at autopsy that would account for death.
Toxicology of a post-mortem blood sample revealed the presence of methadone in the reported fatal range; quetiapine in the high therapeutic range; morphine in the therapeutic range; diazepam in the therapeutic range and THC (ug/L).
The methadone used by Miss Reynolds and supplied to her by Mr Pearsall was in a form to be consumed orally and not intravenously. In his toxicology report, forensic scientist, Andrew Griffiths, stated that if it was administered intravenously the toxic effects associated with the drug would be enhanced due to the greater initial drug level achieved. A drug administered in this method will achieve a much higher blood concentration and peak immediately. Mr Griffiths also noted that the presence of other drugs with depressant action upon the central nervous system, being diazepam, Quetiapine, morphine and THC, would enhance the toxic effects produced by methadone at this high concentration. Dr Lawrence also observed that intravenous injection of methadone, especially accompanied by quetiapine and benzodiazepines, produces unpredictable results.
Mr Pearsall was charged under the Misuse of Drugs Act with 3 counts of supplying methadone, morphine and cannabis respectively to Miss Reynolds on 10 August 2007. Magistrate Mollard, in his sentencing comments, emphasised the danger of supplying illicit substances to others. He sentenced Mr Pearsall to six months imprisonment, suspended on condition that he be of good behaviour and not commit any offences under the Misuse of Drugs Act for a period of three years. He also ordered Mr Pearsall to perform 70 hours of community service and to submit to a 9 month probation order with emphasis upon treatment for drug dependency.
Mr Pearsall, in his affidavit for this investigation, stated that he and Miss Reynolds would regularly inject methadone and morphine, as well as smoke cannabis together. He denied that he supplied her with any other substances but stated that he was aware that she took Valium and ‘sirscal’ (which I interpret to mean Seroquel).
It appears that sadly Miss Reynolds did not receive a stable or nurturing upbringing. Both she and her brother were at times left to fend for themselves at an early age, which included stealing and begging for money and food. It is apparent that their family lives often involved intervention by the police and the Department of Child and Family Services which appeared to not have any positive effect in their behaviour.
The evidence by witnesses and information held by police suggests that Grant Reynolds’ involvement with drugs and crime, and association with other persons so involved, contributed in a significant way to the pattern of behaviour and involvement in drugs and crime by both of his children.
In the last few years of her life Miss Reynolds was living a pattern of crime and prostitution to support her drug addiction and constantly sought out male persons who were able to supply her with the drugs of her needs.
Police records indicate that she had a long list of criminal and drug associates that were in a position to obtain and supply the drugs she sought. Southern Drug Investigation Services and general police have, over a period of years, searched some of these people and charged them where appropriate, however not specifically with supplying Miss Reynolds.
Whilst the evidence indicates that Miss Reynolds engaged in self-harm and destructive patterns of behaviour, she had not been known to be mentally ill. I am satisfied that her consumption of substances before her death was not with a view to intentionally ending her life.
I find that on 10 August 2007 Miss Reynolds, recklessly and due to a substance addiction of a high level, ingested and injected large quantities of methadone, quetiapine, diazepam, morphine and cannabis. The effects of those substances, in particular methadone, caused her death.
I convey my sincere condolences to Ms Reynolds’ family.
Comments:
The death of Miss Reynolds at such a young age in the circumstances outlined above should be of concern to the community as a whole.
A significant issue associated with Miss Reynolds’ death, as well as during her life, is the unlawful supply to her of prescription medication, in particular methadone.
The issue of the abuse of prescribed takeaway doses of methadone by those on the methadone program has been the subject of comments and recommendations by coroners.
In 2008 Coroner Stephen Carey made the following comments in a finding:
"In an investigation finding published on 6 February 2007 which dealt with another case in which the illicit use of take-away doses of methadone had caused death, I made a number of recommendations. In summary, I considered that if as certain evidence suggested, the Alcohol and Drug Service believed that the rate of prescription of take-away doses of methadone was too high then steps ought to be taken to reduce it. Options that may have been considered were to establish explicit and rigorous rules concerning the access to take-away doses, or providing that a request for take-away doses be sanctioned by an expert panel independent from the prescriber. It was apparent that there was a need to ensure that an appropriate balance was achieved between the encouragement of rehabilitation of certain individuals by providing for the ability to be prescribed take-away doses and the alternate being the opportunity to divert those doses for illicit use.
…
Insofar as the misuse and abuse of methadone illustrated by this case, I note that there is presently before interested persons and professional bodies within Tasmania a draft "Tasmanian Opioid Pharmacotherapy Program Policy and Clinical Practice Standards (2008) for the use of Buprenorphine and Methadone in the treatment of opiate dependents (TOPP)". I understand that this provides a conservative and clinical risk management approach to the use of Pharmacotherapy treatment for those persons dependent upon opiate products. This program provides for the use of Buprenorphine rather than methadone as it is at least two orders of magnitude less likely to be associated with an opiate toxicity related death. I also understand that the use of take-away doses would be significantly curtailed and a detailed clinical risk assessment approach would apply to all persons on the program and any person identified as a risk would not receive take-away doses"
In 2009 Coroner Chris Webster stated: "Death relating to illicit overdose of drugs remains a problem within the community. The illicit use of morphine and methadone within Tasmania appears to remain at a high level. Anecdotal evidence suggests that a large portion of legally obtained drugs are being diverted into the illicit market due to the financial gains available."
In 2009 Coroner Carey stated: "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."
I adopt these comments and urge all methadone prescribers to remain vigilant in prescribing takeaway doses of methadone.
The new draft prescribing guidelines (TOPP) referred to above have still not come into force.
Clinical Director of Alcohol and Drug Services, Dr Adrian Reynolds, has provided for this investigation a summary of the new prescribing guidelines referred to in Coroner Carey’s comments above. He states:
"The Alcohol and Drug Service has reviewed the Tasmanian Methadone Policy 2000, and has developed a (new) ‘Tasmanian Opioid Pharmacotherapy Policy and Clinical Practice Standards’ (referred to as the TOPP), in accordance with National policy. This document remains in draft form and is currently going through an internal stakeholder review before going out to external stakeholders for comment, prior to its publishing.
The National Opioid Pharmacotherapy Policy 2007 states that methadone and Buprenorphine should be consumed under direct supervision, but that under certain circumstances it may be appropriate for authorisation of takeaway doses, and further that individual jurisdictions may vary in the limits applied to takeaway doses.
The new Tasmanian Opioid Policy and Clinical Practice Standards will restrict the number of methadone and Buprenorphine takeaway doses to no more than two (2) in any week and these takeaway doses will be provided only when there is very good evidence of clinical stability and evidence that this medication can and will be safely stored by the patient and taken only as directed by their prescribing doctor.
More specifically, a patient will be allowed a maximum of one methadone or Buprenorphine takeaway dose each week after demonstrating three months of continuous clinical stability, as well as a need for and capacity to benefit from such takeaway dose privileges. A patient may be granted two takeaway doses each week but not on consecutive days, when they have demonstrated six months of continuous clinical stability.
These takeaway dose privileges will be removed immediately and for at least three months when there is evidence of poor treatment compliance or other behaviour that is assessed as placing the patient or the public at risk. Where there is evidence that a patient is clinically unstable and at risk, they will be clinically monitored more closely and when willing and within the constraints of available professional resources, will be engaged in appropriate counselling to assist them in addressing their life problems including unsanctioned alcohol or other drug use where this is the issue of concern. Detailed risk assessment and risk management guidelines and clinical management strategies are described in the TOPP. Following the completion and publishing of the TOPP, attention will then focus on training and on networking with, supervising and mentoring prescribers and other health professionals involved in the opioid pharmacotherapy program.
The TOPP includes a risk and protective framework that requires an evaluation of the safety of the home environment as well as the safety of children who may be affected by their parents substance use. The legislation section of the TOPP will also highlight the reporting requirements around neglect and harm to children in accordance with the Children Young Persons & Their Families Act."
I support this revised policy and encourage all those involved to efficiently pursue its implementation in the hope that there will be a reduction in the number of deaths involving the abuse of takeaway doses of methadone.
DATED : Friday 15 July 2011 at Hobart in Tasmania.