Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11

I, Simon J Cooper, Coroner, having investigated the death of Mr A

Find That:

a) The identity of the deceased is Mr A;
 
b) Mr A died in the circumstances set out further in this finding;
 
c) Mr A died of acute right heart failure (cor pulmonale) complicating foreign body (microcrystalline cellulose) granulomas of the lung caused by intravenous drug use (crushed methylphenidate pills injected intravenously);
 
d) Mr A died on 29 April 2014 in Tasmania;
 
e) Mr A was born in New South Wales and was aged 43 years at the time of his death; he was a married man who was unemployed; and
 
f) No person contributed to the cause of his death.

Circumstance Surrounding the Death:

At approximately 8.28pm on 29 April 2014 Tasmania Police and Ambulance Service Tasmania personnel responded to an emergency call and attended an address in northern Tasmania.

Inside the residence officers were met by Mr A's wife. She told them that she had found her husband lying on the floor of their shared bedroom.

Attempts were made by Ambulance Service Tasmania personnel to resuscitate Mr A. Ultimately those attempts were unsuccessful as it was apparent he was dead.

An investigation of the circumstances surrounding Mr A's death was commenced at the scene. Mrs A told attending police that Mr A had injected 18 tablets of Ritalin (methylphenidate) at about 8.15pm. Apparently it was common for Mr A to crush Ritalin tablets, dissolve the powder produced and inject the solution intravenously.  Mr A was not prescribed Ritalin. Despite investigations the source from which he obtained the drug was unable to be identified.

The syringe that Mr A had used to self-administer the Ritalin was located at the scene and taken possession of.

Officers from the Criminal Investigation Branch and Forensic Services also attended the address. Nothing suspicious was identified at the scene. Photographs were taken of Mr A's body in situ and after formal identification, his body was removed from the scene by mortuary ambulance and taken to the Launceston General Hospital, and from there to the Royal Hobart Hospital.

At the Royal Hobart Hospital an autopsy was performed upon Mr A's body by Dr Donald McGillivray Ritchey, forensic pathologist. Dr Ritchey found evidence of a history of drug abuse, specifically multiple recent needle puncture injuries of the bilateral antecubital fossa, the right side of the neck on the anterior left forearm, and wrist.

Samples were taken from Mr A's body for subsequent analysis at the laboratory of Forensic Science Service Tasmania.  That analysis revealed the presence of a considerable number of drugs, with several at levels greater than therapeutic, including Ritalin. Illicit drugs - methylamphetamine and cannabis - were also found to be present in the samples.

The findings at autopsy coupled with the results of toxicological analysis led Dr Ritchey to conclude that Mr A had died of acute right heart failure caused by rising pulmonary artery pressures induced by blockage of blood flow through the lungs by foreign debris (microcrystalline cellulose) and the inflammatory reaction to that debris. I accept this opinion.

In short, Mr A's death was due to his having crushed Ritalin pills and injected them intravenously which caused complications in his lungs, leading to heart failure. The lung complication was caused by microcrystalline cellulose. That substance is present in drugs such as Ritalin, and placed in those drugs by pharmaceutical companies as a binder in the pills. It is insoluble in both water and blood. Once injected intravenously it is deposited within the small blood vessels of the lungs. Because it is insoluble it blocks blood flow.

Comments and Recommendations:

The practice of crushing Ritalin, dissolving it in water and injecting it intravenously is inherently dangerous. In the findings published following an inquest into the death of Luke Rhodes [2014] TASCD, a case concerning a death resulting from the same practice Coroner McTaggart warned as follows:

"1. That the injection directly into the veins of any drugs intended to be swallowed can be lethal due to lung and vascular damage caused by the binding substances in the pill.  Death can occur in this manner as a result of a single injection. Methylphenidate (Ritalin), Xanax and Oxycodone are commonly injected in this manner. The evidence indicates that there is a lack of awareness of this dangerous practice.

2. That medical practitioners prescribing psychostimulant medication such as Ritalin continue to be vigilant in assessing the serious risks associated with such prescription; and to ensure that careful assessment, planning, diagnosis, treatment and monitoring occurs in association with such prescribing."

I repeat those warnings.

Coroner McTaggart made recommendations as follows:

 "(a)  That relevant agencies consider whether there is a need for a public education campaign with a view to reducing the harm caused by illicit diversion of psychostimulants, and in particular, to highlight the dangerous practice of intravenous injection of such substances; and

(b)  That in developing updated guidelines for the issuing of authorities to prescribers, the PSB consider current evidence of the prevalence of and harm caused by diversion and misuse of psychostimulants in the community".

I respectfully repeat those recommendations.

In conclusion I express my sympathy to the family of Mr A.

Dated: 5 June 2015 Hobart in the state of Tasmania.

Simon Cooper
Coroner