RECORD OF INVESTIGATION INTO DEATH (WITHOUT INQUEST)
Coroners Act 1995
Coroners Rules 2006
I, Robert Pearce, Coroner, having investigated a death of
Hannah Maree BLAKE
WITHOUT HOLDING AN INQUEST
(a) The deceased person is Hannah Maree BLAKE born in Invermay on 22 October 1974.
(b) Hannah Maree BLAKE died on 16 July 2010 at 3/40 Pioneer Parade, Ravenswood aged 35 years.
(c) Hannah Maree BLAKE was a single person who was unemployed at the time of her death.
(d) The cause of her death was pneumonia the effects of which may have been exacerbated by respiratory depression caused by the combined effect of methadone and other drugs.
(e) No other person contributed to Ms BLAKE’s death.
Background and Circumstances:
1. Hannah Blake led a difficult and tumultuous life. From about age 14 she exhibited antisocial, destructive and addictive behaviour and was prone to abuse of alcohol and both prescription and illicit drugs. She had a complex and extensive history of physical and mental health issues. She had multiple hospital admissions. She was morbidly obese.
2. She had 3 children, the first being born when she was 16. The difficulties she experienced made it difficult to maintain relationships including with the fathers of her children. She did not have care of her youngest children. However she did have care of her son Ethan aged four.
3. Prior to her death Ms Blake was in the care of her general practitioner, Alcohol and Drug Services and Mental Health Service–North. She was taking multiple prescription medications. She was a long term participant in the methadone program. In the six months prior to her death Ms Blake was being dosed at Newstead Pharmacy with methadone syrup prescribed by ADS North. She received 40mg of methadone syrup on Monday to Friday inclusive was receiving take-aways on Saturday and Sunday. She received doses on Monday 12 July to Thursday 14 July 2010 but was not dosed on the day of her death. In addition to methadone she was prescribed medication by her general practitioner and by Mental Health Service-North.
4. For about the last 4 years of her life Ms Blake lived with her friend Miss Julianne Vandyke. In the week leading up to Ms Blake’s death, she had been unwell with flu like symptoms that impaired her breathing. Despite attempts by Miss Vandyke and Ms Blake’s mother to persuade her to visit her doctor, she refused stating she had an appointment on 16 July 2010 and she would see to it then.
5. On 15 July 2010 Ms Blake was at home. She was helped into bed at about 11.00pm by Miss Vandyke. At approximately 1.00am Miss Vandyke checked on Ms Blake and she was asleep and snoring. By the morning her breathing was shallow and light. Miss Vandyke checked her periodically from about 6.00am but when she checked at 9.00am Ms Blake was not breathing. She was cold to touch and her lips were blue. Ambulance officers were called but pronounced Ms Blake deceased.
6. A post mortem examination conducted by Dr Fernando found that Ms Blake had pneumonia with interstitial inflammation of the lungs and that this was the primary cause of her death. Dr Fernando noted a liver condition associated with alcohol abuse, and mixed drug toxicity as contributing causes. A toxicology report disclosed the presence of many drugs including methadone, tramadol, olanzapine, alprazolam, diazepam and amitrityline, some at apparently elevated concentrations.
Comments & Recommendations:
7. Many of the medications found in the tested sample acted as central nervous system depressants, a common side effect of which is respiratory depression. The effect of respiratory depression is exacerbated in a person with compromised respiratory function. Ms Blake had compromised respiratory function due to pneumonia. The pneumonia, combined with the effect of the drugs she had taken, led to unconsciousness and death.
8. I have decided not to hold an inquest into Ms Blake’s death because the investigation has sufficiently disclosed her identity, the time, place, cause of her death, the relevant circumstances concerning the death and the particulars needed to register the death under the Births, Deaths and Marriages Registration Act. The facts do not justify a finding that any other person contributed to Ms Blake’s death. I do not consider that the holding of an inquest would elicit any information further to that disclosed by the investigation already conducted.
9. It is open to a coroner to make comments or recommendations. That is sometimes done in cases which raise some issue of general public importance. Such an issue arises in this case. That issue is whether there was sufficient communication between the various agencies prescribing of drugs in the course of their treatment of Ms Blake – her general practitioner, Mental Health Services North and the Alcohol and Drug Service. Insufficient co-ordination between such services can lead to inadequate control of medication.
10. As part of the investigation, the issue I have identified was raised with both Mental Health Services North and Statewide Alcohol and Drug Services. The agencies have jointly provided a considered and helpful response from which I will extract some relevant points. It is expected, as standard clinical practice, that practitioners attempt to familiarise themselves with current prescribed medications through liaison with involved services and care providers. A policy has been prepared to address such matters between those services which reflects the standard of clinical practice to which I have referred. From 1 July 2012 Australian doctors and pharmacies will have available access to real time reporting of prescribed opioids and the benzodiazepine alprazolam. However this system will not extend to other prescribed medications for which there is no shared clinical database.
11. The development of such a shared database to which prescribing practitioners have access when required is an optimal solution. However even then difficulties remain. Ms Blake was not an easy patient. As with all patients management of medication is made more difficult by accumulation of previously prescribed medication and the inability to compel return of superseded medication. In this case at least Mental Health Services North was aware of the issue and was attempting to achieve a co-ordinated approach and administer a treatment plan. Even so, the combination of prescription drugs Ms Blake was able to obtain and self-administer likely contributed to her death.
12. I have concluded that this is not an appropriate case for further investigation of that issue. However I would encourage increased and continued co-ordination between the agencies as I have described.
I convey my sincere condolences to Ms Blake’s family.
DATED 10 May 2012 at Launceston in the state of Tasmania