A woman who died on her couch from drug toxicity died due to serious breaches of the standards related to excessive and early access to morphine, and other drugs, a coroner has found.
Coroner Simon Cooper on Monday released his findings into the death of Melissa Mary Spencer and found several breaches of the Poisons Act related to the prescription of morphine, along with the cocktail of other drugs Ms Spencer was prescribed for chronic pain.
Ms Spencer, a nurse, suffered a significant back injury on November 5, 1990, aged 26, which resulted in chronic pain treated by her general practitioner. She also had a history of falls.
One year before her death she suffered a fall and fractured ribs and injured her shoulder. Six to eight weeks before her death she also suffered significant bruising to one of her arms. Two or three weeks prior to her death, Ms Spencer reportedly sustained another fall, which resulted in minor cuts to he head.
At the time of her death, on June 24, 2019, Ms Spencer had been prescribed six different medications, including Kapanol, Mersyndol, Temazepam, Nexium, Prozac and Sotacor.
The majority of these medications are designed for short-term use, but Ms Spencer's medical records showed she had been using them for many years.
Mr Cooper said an autopsy report and medical report issued following Ms Spencer's death, showed there had been elevated levels of morphine and doxylamine in her system.
Four of the drugs prescribed to Ms Spencer are depressants - morphine, codeine, doxylamine and nitrazepam - which can result in symptoms including feeling sleepy and uncoordinated, staggering, blurred vision, impaired thinking, slurred speech, impaired perception of time and space, slow reflexes and breathing, decreased heart rate, reduced sensitivity to pain and loss of consciousness possibly leading to coma or death.
"The evidence satisfied me to the requisite legal standard that the cause of Ms Spencer's death was mixed drug toxicity," Mr Cooper said in the report.
"It is evident from the exhibits found at the scene and the results of toxicological analysis of samples taken at autopsy, that Ms Spencer was prescribed a large number of drugs. Several of those drugs were central nervous system depressants. A number of those drugs were prescribed for many years but designed only for short term use."
Mr Cooper said it was quite apparent that "there has been significant departure from the standards required by the legislation which governs the prescription of schedule 8 drugs. Particularly concerning are the 20 breaches relating to excessive and early supply of morphine to Ms Spencer."
Ms Spencer had been declared by a medical practitioner in Tasmania to be drug dependent on February 1996, following her back injury.
However, the legal requirements state if a patient had been previously declared drug dependent an authorisation to continue to prescribe is required. Mr Cooper said there was no evidence this occurred.
"The PSB records indicate that since 2009 there were 112 breaches of the Poisons Act 1971 in relation to the supply of relevant substances to Ms Spencer."
Mr Cooper said the circumstances of Ms Spencer's death highlighted the dangers associated with long-term use of narcotics and other central nervous system depressant drugs.
"I comment that the system established by the Poisons Act 1971 to regulate the prescribing, dispensing and use of narcotic and similar drugs is important to ensure their safe use."
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