Record of Investigation Into Death (Without Inquest)

Corners Act 1995
Coroners Rules 2006
Rule 11

I, Michael Brett, Coroner, having investigated the death of Steven Paul JONES.

Find that:

(a) The identity of the deceased is Steven Paul Jones:

(b) Mr Jones was born on the 17th February 1964 at  Burnie in Tasmania;

(c) Mr Jones died on the 28th April 2012 at his home at 9 Jowett Street, Ulverstone in Tasmania;

(d) The cause of Mr Jones’s death was toxicity arising from consumption of prescription drugs; and

(e) No other person contributed to the cause of Mr Jones’s death.

Circumstances Surrounding The Death of Mr Grosse:

At the time of his death, Mr Jones was residing with his wife, Bethany Jones, at their home at 9 Jowett Street, Ulverstone. He was not in employment, having retired for medical reasons from his employment with Australian Paper Mills in early 2010. He had, by then, been in that employment for 28 years.

In March 2010, Mr Jones was diagnosed with bowel cancer. The cancer was removed surgically in September 2010 and was also treated with chemotherapy and radiation therapy. In September 2011, there was further surgery, which included a colostomy with bag placement.

In addition to the cancer, Mr Jones had a number of other long-standing health issues. These included hypertension, anxiety, depression and concerns about short-term memory loss. He also suffered from chronic back and leg pain. This pain may have been related to stenosis in the lumbar region.

Mr Jones had been prescribed a formidable range of medications since at least 2010. Some of these were medications intended to provide pain relief. From that time, he was under the care of various palliative care medical specialists including Melwood palliative care unit at St Luke’s Hospital in Launceston. There had been a number of attempts by these specialists to rationalise and reduce the medications, but only with partial success.

Between 20 March 2012 and 29 March 2012, Mr Jones was admitted to Melwood palliative care unit under the care of Dr David Woods, a palliative care medical specialist. The purpose of this admission was to manage Mr Jones ongoing chronic pain. During this admission there was significant review of ongoing medication, including medication in respect of pain relief.

Mrs Jones in her statutory declaration indicates that she had been concerned about the level of medication prescribed for Mr Jones for some time. She had expressed concerns about this to his general practitioner approximately six months before Mr Jones’s death. Mrs Jones states that his admission to the palliative care unit in March 2012  was at her instigation because of her concern about the level of medication. She believed that the level of medication, in particular methodone had been reduced, while he was in hospital but because of pain levels, the dose went back up after his release from hospital. She states also that, after his release most of the time he was out of it. He was unaware of what was going on around him.

On 27 April 2012, Mr and Mrs Jones went to bed at the usual time. Mr Jones had had his medication prior to going to bed. It had been given to him by Mrs Jones. He had had a minor accident with his colostomy bag that day, which had depressed him, but Mrs Jones believes there was nothing else concerning him. They woke at about 5 am, talked for a while and then went back to sleep hugging each other. Mrs Jones woke again at around 10:40 am. Mr Jones was cold to touch, his lips were blue and his tongue was protruding. He was unresponsive. She called an ambulance and attempted CPR. Ambulance officers arrived shortly after, and determined that Mr Jones was deceased.

An autopsy was conducted by pathologist, Dr Terry Brain. Dr Brain, relying primarily on toxicology results, expressed the opinion that it is highly likely that the cause of death was mixed drug toxicity. The toxicology results demonstrate high therapeutic to therapeutic levels of a number of drugs, consistent with drugs which were, or had been, prescribed for Mr Jones.

The evidence in this matter, including the autopsy report and toxicology results has been reviewed by Dr Anthony Bell, a medical consultant. Dr Bell’s opinion can be summarised as follows:

a. He agrees with the opinion of the pathologist that death resulted from mixed drug toxicity. He notes that the toxicology results demonstrate the presence of high therapeutic levels of oxycodone and therapeutic levels of  methadone. He notes that the combination of these two drugs increases the risk of toxicity. He considers that whilst the hospital admission may have been partially successful in rationalising Mr Jones’ drug use, the presence of  oxycodone and methadone in the levels stated suggests that he went back to previous dose levels upon leaving hospital. This is also consistent with Mrs Jones’ statement that Mr Jones had increased his dose of pain relief medication after leaving hospital, and her observation of his condition. Dr Bell considers that the return to pre hospital levels of these drugs would have increased the risk of toxicity.

b. Dr Bell considers that the treatment received by Mr Jones during the hospital admission in March 2012 was satisfactory. He considers that the medication used and their combination was appropriate, given the level of pain being experienced by Mr Jones.  In particular, the cessation of oxynorm and a reduction in methadone was appropriate and designed to avoid the effect of toxicity. He notes that the abrupt change whilst in hospital from paroxetine to mirtazapine was contrary to current recommendations and that this change in drug should have occurred by a process of cross tapering. However, his opinion is that it is unlikely that this change induced drug toxicity or had any role to play in the cause of Mr Jones’s death.

c. Dr Bell considers that the evidence does not support a conclusion that Mr Jones took a large deliberate overdose of drugs. A return to previous dosing levels would be sufficient to account for an increased risk of toxicity. He considers it likely that this risk materialised, resulting in Mr Jones’ death.

d. Dr Bell notes that there appears to be minimal evidence for active disease in respect of the bowel cancer. He does not consider that the cancer was directly responsible for Mr Jones death.

It is reasonable to consider the possibility that Mr Jones caused his death by a large deliberate overdose of medication. It is clear that Mr Jones struggled with chronic pain and the impact of his cancer and its treatment, including the colostomy bag. Further, Mrs Jones indicates that he had often talked about taking his own life . As recently as February 2012, whilst working on the roof of a shed at their home, he had threatened that he was going to jump from the roof, but had been persuaded not to by Mrs Jones. He had often talked about committing suicide by an overdose of medication.

Despite this, the evidence would seem to exclude that Mr Jones caused his own death in this way. The primary evidence in contradiction of  this possibility, is that it was, in fact, Mrs Jones, who administered his medication on the night before his death. There is nothing about his demeanour or conduct when they went to bed or awoke at 5am which is consistent with an attempt at suicide. I note also that Dr Bell’s opinion based on the toxicology results is that a deliberate overdose is unlikely.

I am satisfied that the most likely cause of death is toxicity arising from the medication being taken by Mr Jones, in particular, the opiates, oxycodone and methadone.  I think that it is highly likely that he did unilaterally increase the amount of opiate pain relief he was consuming after leaving hospital, probably from accumulated stock from earlier prescriptions, and that this increased level of drugs consequently increased the risk of toxicity. This risk materialised, resulting in Mr Jones’ death. The evidence does not permit findings which are more specific than this.

Comments and Recommendations:

 I have decided not to hold an inquest in this matter.  In my opinion, no further information of significance or relevance to the issues which I am required to determine will be elicited by an inquest.

There is no need for me to make any recommendation. In particular, I accept Dr Bell’s opinion that Mr Jones’s treatment was appropriate and within applicable guidelines. He notes that toxicity is a risk with all drugs and that pain medication is an active area of medical research.

I take this opportunity of conveying my sincere condolences to Mrs Jones, Mr Jones’s sons, and other family members and friends.

DATED:  8 July 2014   at Devonport in the state of Tasmania.           

Michael Brett