Record of Investigation into Death (Without Public Inquest)
Coroners Act 1995
Coroners Rules 2006
These findings have been partially de-identified by direction of the Coroner pursuant to S.57(1)(c) of the Coroners Act 1995
I, Stephen Raymond Carey, have investigated the death of
WITHOUT HOLDING AN INQUEST
a) The identity of the deceased is 'Ms W' who died at her residence in Southern Tasmania at a precise date and time unable to be determined but most likely in February 2012.
b) 'Ms W' was born in Lismore, New South Wales in December and was aged in her 50's at the date of her death.
c) 'Ms W' was unemployed at the time of her death.
d) 'Ms W' was married but separated.
e) 'Ms W' died as a result of mixed prescription drug toxicity (Alprazolam and Propoxyphene). Significant contributing factors were a clinical history of Bipolar Affective Disorder, obesity and probable peri-mortem aspiration of gastric contents.
Circumstances Surrounding the Death:
In 1988 'Ms W' and her family moved to Southern Tasmania where they purchased a property. During the next few years 'Ms W' was unable to find employment and her husband, 'Mr S' organised for her to be admitted to receive Government benefits due to ill health as she had previously been diagnosed as suffering Bipolar Affective Disorder. 'Dr A' was 'Ms W' treating general practitioner throughout her period in Tasmania. He reports as follows:
"I have been seeing 'Ms W' as a General Practitioner for at least twelve years. She was initially referred to me by her then treating Psychiatrist, 'Dr W'. She had a psychiatric diagnosis of Bipolar Affective Disorder which was treated with Lithium Carbonate 450 mgs twice daily. Her blood levels were checked fairly regularly and I include her most recent results. She also used Alprazolam (Zanax) 2 mgs on an as needed basis. The last prescription for this was given on 8 February 2012 for 50 with two repeats. She usually received two prescriptions for this per year, checking back over the past four years in my records. She also took Thyroxine 200 mcgs five days a week and 100 mcgs two days a week for Hypothyroidism."
It is apparent that just after Christmas 2011 whilst visiting her brother in Sydney 'Ms W' was admitted to a psychiatric institution. Apparently she had travelled to her brother's residence arriving unannounced and without luggage. She stayed for three days and during this period he noted that she had trouble sleeping, was restless and appeared paranoid. Apparently 'Ms W's' son also became concerned as to her condition and he called an ambulance service which took her to the psychiatric facility at Manly Hospital. It is apparent that this episode had been caused by 'Ms W' ceasing to take her prescribed Lithium medication three months prior to that date. Her discharge summary shows that 'Ms W' acknowledged that she needed to remain on Lithium as she reported that each time she had stopped it she had ended up in hospital within a few months. At the time of her discharge she was settled, both in mood and behaviour, and she was assisted in obtaining a return flight to her home in Tasmania.
Upon her return she was seen by 'Dr A' on 9 January 2012 at which time she was optimistic that the treatment she had received was helpful and she seemed settled and stable mentally. This was his last consultation with 'Ms W'.
As to the lead up to 'Ms W's' death, on 6 February 2012 she was visited by 'Mr P' and his cousin 'Ms P' who had been asked by 'Ms W' the previous day to visit in order to set up a television set. Both 'Mr P' and 'Ms P' had been at her home on previous occasions to carry out tasks for her including painting her dining room and mowing lawns. After setting up the television the three had a discussion about future proposed improvements to 'Ms W' residence. On Wednesday 8 February 2012 'Ms W' had a telephone discussion with her sister, 'Ms M', the two having not seen each other since 21 or 22 December 2011.
On Monday 13 February 2012 'Mr P' and 'Ms P' returned to 'Ms W's residence and spoke to her about coming around to paint her kitchen on Thursday 16 or Friday 17 February. Arrangements had been made to commence at that time with the job to take approximately two days. On Monday 13 February 'Ms W' son 'Mr S' received seven text messages on his mobile phone from his mother. The last message was sent at 7.47 pm on 13 February 2012.
On Tuesday 14 February 'Ms W's brother, 'Mr W', spoke to her by telephone. During that conversation 'Ms W' described that she had had painters over to work on her house and that she was doing renovations to the kitchen. She advised him that they were due back on the following day to do another room and that she also intended to have her lounge suite reupholstered. During this conversation 'Ms W's brother was of the opinion that she appeared excited about the things they had talked about and that generally she was in a positive mood. Later in the day on Tuesday 14 February 2012 'Mr P' and 'Ms P' realised that they would not be able to commence the painting work when they thought and tried to contact 'Ms W' to remove their painting equipment so as is would not be in her way. 'Ms P' attempted to phone 'Ms W' on several occasions over the next couple of days on both her mobile phone and land line without success. Neither 'Mr P' nor 'Ms P' gave much thought to not being able to contact 'Ms W' as she had previously said to them that on some days she just didn't want to talk to anybody and just wanted to be by herself. On Thursday 16 February 'Mr P' and 'Ms P' went to 'Ms W' residence with the intention of advising her that they would not be able to begin painting until Monday 20 February. Upon their arrival they noted 'Ms W's vehicle parked in the garage, her shoes were outside the front door, but they were unable to raise her after knocking on the front door and calling out to her. They then walked around the house and could not observe 'Ms W' anywhere on the property so then departed. On Saturday 18 February 'Mr P' and 'Ms P' attended a garage sale located near 'Ms W's residence. They went to her residence again and noticed her vehicle was still parked in the garage. They again tried to raise her attention by knocking on the front door but without success. At approximately 8.30am on Sunday 19 February 'Ms W's son, called her brother, 'Mr W', and advised him that he had been attempting to telephone his mother numerous times over the past couple of days without getting a response. At approximately 9.30am 'Mr W' telephoned 'Ms W' sister, 'Ms M', to ask her to drive from her home at 7 Mile Beach to Synnetts Road to check 'Ms W'. At approximately 3pm 'Ms M' arrived and once again could not raise 'Ms W' after knocking at the front door which was locked. She also called out and did not receive a reply. 'Ms M' was able to locate an open window and called out to 'Ms W' through that opening. When there was no response she entered the residence via that open window. Upon entering the residence 'Ms M' noticed 'Ms W' lying face down in the bedroom. 'Ms M' noted that 'Ms W' was cold, and there was a blood pattern on her skin. She could also not ascertain a pulse. Police were then called and attended.
A forensic examination of the scene and body was undertaken and there were no apparent signs of violence on the body or in the residence. Although a number of items on the floor in the doorway of 'Ms W's bedroom appeared to have fallen onto the floor from the bedside drawers, this was apparently as a result of 'Ms W' falling to the floor.
The autopsy of 'Ms W' revealed a well-developed, obese (obesity defined as a body mass index of greater than or equal to 30kg/m²) adult Caucasian woman in a moderate state of post-mortem decomposition. Although the autopsy was somewhat limited by decomposition, microscopic sections of lung viewed under polarised light, demonstrated focal but marked foreign material in alveoli representing probable aspiration of gastric contents.
Toxicology testing of blood obtained at autopsy revealed a markedly elevated concentration of alprazolam and a "therapeutic concentration of propoxyphene". Both medications are strong central nervous system depressants that the pathologist notes were capable, especially in combination, of causing unconsciousness during which time 'Ms W' was unable to protect her airway resulting in aspiration.
During the investigation concern was raised as to the medical appropriateness of prescribing the use of alprazolam and Propoxyphene together. Apparently action was commenced in or about December 2011 by Therapeutic Goods Administration of the Department of Health and Aging concerning the use within Australia of medication containing dextropropoxyphene (Propoxyphene). An initial decision to cancel the use of such medication from 1 March 2012 was appealed to the Administrative Appeals Tribunal who in June 2012 determined that the cancellation decision be referred back to the Therapeutic Goods Administration for reconsideration. On 12 December 2012 the decision to cancel these medications was affirmed by the Therapeutic Goods Administration. Dextropropoxyphene is a centrally acting, synthetic opioid analgesic with a structure relationship to Methadone. Its potency is from 2/3 to equal that of Codeine.
'Dr A' provided further advice to this investigation in November 2012. He provided as follows:
"Further to our conversation this morning regarding 'Ms W', I can provide further details regarding prescriptions for propoxyphene or paradex to 'Ms W'.
'Ms W' had been prescribed paradex on three occasions. On 11th March 2009 for analgesia after fracture to her left arm, on 4th August 2010 after a fall causing dislocation and spontaneous reduction of her patella and in July 2011, once on 8th July 2011 by my colleague 'Dr H' and 20th July 2011 by myself after a motor vehicle accident on 7th July 2011. These prescriptions were for 20 tablets.
I am now aware of caution being recommended for the combination of propoxyphene and alprazolam due to inhibition of hepatic enzymes but was not aware of potential life threatening consequences. 'Ms W' had taken propoxyphene in the past."
This advice was considered by an independent medical specialist, 'Professor B' whose opinion was as follows:
"Ms W' was prescribed dextropropoxyphene on three occasions by 'Dr A' and his colleague 'Dr H'. All three occasions occurred after significant physical trauma and were for pain relief associated with the traumatic event."
'Professor B' goes on the note that this type of short term use is the safest manner in which to use the drug propoxyphene. He notes that the prescription details outlined by 'Dr A' is confirmed by the pharmacist's report and therefore concludes that 'Ms W' presumably kept some of the dextropropoxyphene for later use. The Pharmacy records confirm that 'Ms W' had previously taken dextropropoxyphene and alprazolam in combination without apparent side effects.
The investigation has been unable to determine why 'Ms W' thought it necessary to be taking propoxyphene at the date of her death.
'Professor B' suggests two manners in which the combined use of this drug may have proved fatal on this occasion. Firstly, he notes that given the high dose of alprazolam found at post mortem that 'Ms W' may have actually taken a higher dose than usual. Alternatively it is possible that 'Ms W' accumulated alprozalam in her blood stream due to the metabolic change induced by the use of propoxyphene.
In any event, having considered the circumstances surrounding 'Ms W's death there was nothing to suggest that her death was a result of any deliberate action taken by her to self-harm. The medication toxicity I consider developed accidentally and also where 'Ms W' was unaware of the potential risks of combining the medication that she was taking. The prescription of the propoxyphene by her treating general practitioner occurred well before authorities commenced action to control and cease the use of this medication in Australia.
Comments and Recommendations:
This tragic and accidental death serves as a reminder of the inherent potency of medications and the need for caution in using left-over medication.
Before I conclude I wish to convey my sincere condolences to the family of 'Ms W'.
Dated: 7 day of February, 2013 in Hobart the state of Tasmania