A Coroner has called for stricter processes for Voluntary Assisted Dying (VAD) after an inquest into the death of a grief-stricken spouse who misused surplus VAD drugs.
Central Coroner DJ O’Connell delivered reasons for his decision on 11 September into the tragic case of “ABC” from May last year, where the widowed elderly person consumed the unused VAD self-administration substance instead of returning it to authorities, as required, for disposal.
The inquest investigated whether Queensland Voluntary Assisted Dying (QVAD) staff appropriately sought return of the unused substance, and “whether the process for self-administration of VAD substances could be made safer by it remaining under the control of an authorised health professional, while balancing the recognition of privacy, compassion and autonomy interests of patients and their families”.
The VAD substance had been prepared in Brisbane at the one pharmacy in the state approved to prepare it, and it had been personally delivered by a QVAD staff member to the patient at their location in a regional town.
After a bout of COVID-19, the VAD patient had remained in hospital, where a VAD substance had been eventually supplied and administered by a medical practitioner.
“Of some interest to me is that the then VAD procedures did not require the return of the self-administration VAD substance in exchange for the medical practitioner administered substance, so in fact this patient had two doses simultaneously made available to them,” Coroner O’Connell said.
“After the VAD patient passes away, ABC becomes, most understandably, very despondent and overcome with grief such that their adult child described that ABC was ‘quite unable to function’.”
Eight days later, ABC was discovered deceased by the adult child, having administered the surplus VAD substance to themselves.
Coroner O’Connell said the fact ABC had been medically diagnosed with depression had not been considered, or inquired upon, when they were approved as a Contact Person.
“Indeed, there are simply no checks or enquiries of the Contact Person’s suitability for that position. They simply need to state they are over 18 years of age and provide a name and contact details. These are not checked against anything,” he said.
“At the inquest, it was conceded that a person is required to undergo greater identity checks to enter a nightclub in Brisbane, than to become a Contact Person. Under the current regime the person may have a significant criminal history or extensive mental health issues, yet not one background check is made.”
Coroner O’Connell said the case showed it was “clear that the system and its purportedly rigorous ‘checks and balances’, had several operational flaws”.
“The real tragedy is that it took just 107 days of the new laws’ operation for the flaws to be fatally exposed,” he said.
“It was, in my respectful opinion, not a well-considered law”.
He questioned why such a dangerous medication was removed from the direct and immediate control of a health practitioner until it was ready to be used, saying this issue was “the very centre of the flaw in the current system”, which began operating on January 1 last year.
Coroner O’Connell said there was no breach of protocol or legislative processes by QVAD staff because the obligation was solely on ABC to return the unused substance.
“I do not think the compassionate approach thought to be achieved by the government, and their legislation, is in fact what operates in practice,” he said.
He said the VAD substance was “simply handed over for future use (purportedly for us to 12 months) to an ordinary citizen with no medical training, no health authority registration, and no professional body oversight whatsoever”.
“The person has not even been screened by way of any ‘character’ test or any identification or assessment at all,” he said.
“This highly dangerous drug can then, in practical terms, simply be left on the kitchen table of a patient’s residence because where it is kept, how securely it is stored, where the keys to the lockbox are stored (if indeed the box remains locked), is entirely left with the patient or their Contact Person.”
Coroner O’Connell said ABC’s death was not a “one off” anomaly.
“The current system is imperfect. Further calamity and heartbreak await for patients and families if nothing changes,” he said.
The laws did not have an appropriate balance between patient autonomy and lethal medication safety, he said.
“I do hope that the Government is wise enough to read and consider these reasons, and then act appropriately and implement the required changes to the VAD oral substance administration system,” he said.
“The situation, and its occurrence, is more prevalent than what the Government may appreciate, and persons should not be placed in a position where they can be led into unwise decisions due to grief and an overwhelming despondency caused by the loss of their loved one.”
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