Coroners Act 1995
Coroners Regulations 1996
Regulation 14
Form 4

I, Stephen Raymond Carey, Coroner, having investigated the death of

“‘the deceased”



‘the deceased” died on 7 May 2005 at the Royal Hobart Hospital, Liverpool Street, Hobart.

‘the deceased” (the deceased) was born in Hobart on 12 May 1918 and was 86 years at the time of his death. He was a widower and was retired.

I find that the deceased died as a result of complications of combined benzodiazepine and opiate toxicity, following an intentional overdose of prescribed medication.

At the time of the deceased’s death he was being treated by a medical practitioner.


The deceased resided at his home.

For some time the deceased had suffered severe pain due to osteoporosis and severe degenerative osteoarthritis of the thoraco lumbar spine. On the evening of 3 May 2005 he rang his daughter in law, and asked her to come and stay with him in order to care for his cat as he anticipated he would be obliged to go to hospital in order to undergo treatment for this back pain.

The deceased was admitted to hospital on 4 May 2005, however he discharged himself on 5 May 2005 and was at his home at 1.30pm that day when “his daughter-in-law” arrived. It was apparent to her that the deceased was markedly restricted due to his back pain and he went to bed shortly after she arrived. He stayed in bed throughout the next day as a decision had been made between he and “his daughter-in-law” that he ought rest. The deceased administered his own medication throughout this time. “his daughter-in-law” checked up on him from time to time and at approximately 7.45pm she noted that he had ceased snoring, but appeared to be asleep with his mouth open. When she moved to the other side of his bed in order to “wet his mouth” with some water she discovered a number of empty blister medication packs of MS-Contin. This was a prescribed slow-release morphine based pain relief medication.

“His daughter-in-law” rang the deceased’s treating GP who called an ambulance. It was apparent to all involved at this stage that the deceased had taken an overdose of his prescribed medication. When he arrived at the Department of Emergency Medicine, Royal Hobart Hospital he was placed on infusions of Narcan and Flumazenil to counteract the Morphine and as a result of this his condition stabilised somewhat. He was admitted to the hospital, however after discussions with “his daughter-in-law” concerning her belief that the deceased had a clear wish to die, the admitting doctor marked the deceased’s medical records with an entry that he was not to be resuscitated. Next morning the deceased was reviewed by consultant physician Dr John Freeman together with his Registrar Dr Julian Keats. Dr Freeman made the decision to discontinue the infusions of Narcan and Flumazenil and to maintain palliative care only. At this time he also directed that upon the death of the deceased there was to be no report to the Coroner.

The deceased was discovered dead in Ward 2B South at approximately 7.50pm on 7 May 2005.

Mr John Chapman, the after hours clinical nurse manager of Medical and Surgical at the Royal Hobart Hospital became aware of this case and had misgivings concerning the instruction by Dr John Freeman not to advise the Coroner of this death. Upon receipt of legal advice he contacted Coroner’s Office Hobart and an investigation was initiated.

The investigation was hampered by the delay in notification however it concluded that there were no suspicious circumstances and that the deceased had died as a result of a deliberate self-induced overdose of prescribed medication.

The investigation has however identified a number of matters deserving of comment.


  1. None of those persons initially involved after the discovery of the deceased (including the attending ambulance officers and medical staff at the Royal Hobart Hospital) advised the Police of this incident. As a result of this and the subsequent loss of relevant items and other evidence the Police investigation was significantly hampered. There is a Memorandum of Understanding between Tasmania Police and Tasmanian Ambulance Service concerning Police involvement at the scene of self-administered drug overdose situations. In summary this provides that Police will only be advised of same when the person has died or Ambulance officers require Police support. The underlying principle of this understanding is to ensure that medical assistance is sought in overdose situations and that it is not deterred by the fear of a Police presence. In my view this memorandum was intended to cover the use of illicit drugs and does not apply to a case such as this where prescribed drugs were involved and the circumstances do not create a risk or threat of Police investigation relating to drug related offences.

    I recommend that Tasmania Police and Tasmanian Ambulance Service reconsider the intent of their Memorandum of Understanding in order to provide clarification to their respective officers and staff upon its applicability to drug related scenarios.
  2. Clear guidelines and procedures must be established at the Royal Hobart Hospital and other hospitals in order to ensure that objective assessments are able to be made concerning what cases are “reportable deaths” within the meaning of the Coroners Act 1995. It is not appropriate that such determination be as a result of a subjective view taken by a medical practitioner as occurred in this case. Dr Freeman was adamant that this death was not to be reported due to his view that the deceased “....was dying”. This opinion which apparently was also the reason why he directed that the infusions were to cease, was apparently based on an inaccurate diagnosis of “disseminated malignant disease” which was shown upon post mortem not to be present. There can be no doubt that this was a “reportable death” as it was unnatural and there was no doubt to all involved that it followed a self induced drug overdose. Dr Freeman was wrong as to his diagnosis and wrong in his instruction that this was not a reportable death. The other staff at the Royal Hobart Hospital who sought a review of this instruction are to be complimented, however they ought not have been placed in such a position. An easy to follow check sheet ought be devised that allows an objective decision to be reached as to whether or not a particular case is a “reportable death” under the Act.

    I recommend that consideration be given by the appropriate authorities to the development of such a check list or similar form.
  3. Due to the late notification of the Police in this case and initial action taken by staff owing to the instruction that this was not a reportable death, the used and unused medication belonging to the deceased was disposed of. No criticism is made of the attending Ambulance officers who collected all of this material and took it with them to the Royal Hobart Hospital. Clearly there would be a need to have this information available to those who would be required to treat the deceased upon his admission to hospital.

However, the investigation in this matter disclosed a number of concerns relating to the possession and control of drugs within the Royal Hobart Hospital in cases such as this. In particular:

  • There does not appear to be any protocol applicable to the recording or documenting the medication brought with a patient to the Accident and Emergency Department of the Royal Hobart Hospital. I am advised that medications left behind by patients in the Department of Emergency Medicine are placed in what is called the “chuck out box”. This is located in the doctor’s office and there is no register to record items placed in that box.
  • The deceased’s medication in this case was transferred with him to the Ward upon which he was admitted. However, although these medications were placed in a locked drug cupboard, there was no entry of this medication in the narcotics register. In those circumstances it is possible that there had been a breach of the Poisons Regulations 2002.
  • Although not specifically raised in this investigation there is a possibility that there is also a lack of a clear protocol for the destruction of patient medication where a patient dies after admission to hospital.

All of the above situations provide an unacceptable risk or opportunity that medication including narcotic medication could be acquired by persons for their own use.

I recommend that the appropriate management personnel at the Royal Hobart Hospital address these issues relating to the documentation, storage and disposal of medication that accompanies a person upon presentation to the Department of Emergency Medicine or upon admission to the hospital.

It is unfortunate that effective pain relief treatment could not have been established for the deceased and that he was driven to take this step to end his suffering. In this regard I note that his medical treaters appeared to be of the view that he was suffering from a terminal illness which was not the case and had they known this then a more directed effort may have been able to be made to address the pain flowing from the deceased’s back condition. I also note, however that endeavours in this regard were hampered by the deceased’s own reluctance to remain in hospital in order to allow more intensive endeavours to be made to address the pain he was suffering.

Before I conclude this matter I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded.

Dated this 9th day of February 2006.