Coroner's Finding: Stocks, Michelle Jayne

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 I, Olivia McTaggart, Coroner, having investigated the death of Michelle Jayne Stocks Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is Michelle Jayne Stocks; b) Ms Stocks died in the circumstances set out in this finding; c) The cause of death was accidental mixed prescription drug toxicity (tramadol, amitriptyline, codeine, diazepam, alprazolam); and d) Ms Stocks died between 22 and 23 December 2018 at Cygnet in Tasmania.

In making the above findings I have had regard to the evidence gained in the comprehensive investigation into Ms Stocks’ death. The evidence includes:  The Police Report of Death for the Coroner;  An opinion of the forensic pathologist who conducted the autopsy;  The results of toxicological analysis of samples taken at autopsy;  Affidavits confirming identification and life extinct;  Affidavit of Jayden Stocks, son of Ms Stocks;  Affidavit of Jason Cowd, friend to Ms Stocks;  Four affidavits of attending and investigating police officers;  Medical reports and records from Dr Q (name withheld but for the purposes of this finding referred to as Dr Q), Ms Stocks’ general practitioner;  Medical report from Dr A J Bell, coronial medical consultant;  Medical reports and records from the Department of Health – Pharmaceutical Services Branch (PSB);  Information from Tasmania Police holdings; and  Forensic and photographic evidence.

Background Ms Michelle Jayne Stocks was born in Hobart on 16 May 1972. At the time of her death, she was aged 46 years and lived on her property at Cygnet with her two children.

Ms Stocks was born to Gloria Stocks, now deceased, and an unknown father. Ms Stocks had six siblings, but only kept in contact with her sister, Alexis, and her brother, Tim. Ms Stocks moved to the Cygnet area when she was a child and grew up there. Ms Stocks had been living in Cygnet since 2010.

Ms Stocks was a waitress and fruit picker during her working life, although at the time of her death, she was unemployed and in receipt of a disability pension.

Ms Stocks had never been married, although she had several brief romantic relationships. Ms Stocks has three sons: Matthew Stocks (born 1991), Jayden Stocks (born 2001) and Kale Stocks (born 2010), each of whom have different fathers.

Ms Stocks had a considerable medical history. She was a moderate to heavy smoker and suffered from centrilobular emphysema. She also suffered from persistent headaches and fatigue, fibromyalgia, classical migraines, loin pain haematuria syndrome, lower back pain, urogynae issues post-delivery of her first child in 1991, oesophageal dysmotility and overactive bladder syndrome.

Ms Stocks was under the regular care of her general practitioner, Dr Q, who prescribed her medication for her pain and her medical conditions. Her son, Jayden Stocks, said that Ms Stocks would refuse to take the prescribed amount of medication, instead taking it as she thought she needed.

In 2010, Ms Stocks was suspected of selling prescription drugs. On 4 April 2010, police searched Ms Stocks’ residence and found a large amount of prescription drugs, all of which had been prescribed to her mother, Gloria Stocks, over a period of two years. Ms Stocks was interviewed and said that she was her mother’s legal guardian and would fill her script for her.

Ms Stocks said that she would give her mother each type of medication in a dosage that she determined, a dosage that did not match the doctor’s or pharmacist’s directions. Ms Stocks would continue to purchase new medication to ‘stockpile it’ for a later date. Even after Gloria Stocks became a permanent resident at a nursing home, Ms Stocks still kept the medication.

She was adamant that she was not selling any medication.

In February 2018, Ms Stocks travelled to Queensland to manage an animal refuge in Cairns.

During this time, it seems that she was under the care of an unknown doctor (or doctors) in

Cairns. Prior to leaving, Dr Q prescribed her regular medications sufficient to last for one month.

In December 2018, Ms Stocks returned to Tasmania and visited Dr Q on 10 and 14 December

2018. At the first of those consultations, she requested him to re-fill her prescriptions as they were before she left. In making this request, Ms Stocks presented to him a hand written list of the medications that she required, which she stated had been prescribed to her in Queensland and which she had run out of in the road trip back to Tasmania. Dr Q prescribed her these medications as he was aware that they were essentially the same as those that he had continually prescribed her for many years whilst she was in Tasmania. The prescriptions issued by Dr Q included oxycodone (reduced dose), temazepam, valium, panadeine forte, tramadol and lyrica. However, as discussed below, he did not take some important steps to ascertain that such prescribing was safe in the circumstances.

Circumstances of Death On the afternoon of 22 December 2018, Ms Stocks went to the Cygnet Hotel with her friend, Jason Cowd, who she met in Cairns and who was staying with her. There, they both had a number of drinks before returning to Ms Stocks’ property. Ms Stocks continued to drink Kahlua (a coffee flavoured liqueur) when at home and, at 9.00pm, had to be assisted to bed by Jayden and Mr Cowd. Her bed was located in a campervan outside the home.

At about 10.45pm, Mr Cowd also went to bed, intoxicated. He slept on the bunk in the rear of the campervan, while Ms Stocks slept in a bed at the front. He awoke at 10.00am the next morning, 23 December 2018, and left Ms Stocks in her bed, believing her to be asleep.

At 2.30pm that day, Jayden was concerned that Ms Stocks had not yet woken and went with Mr Cowd to the campervan to investigate. There, they found Ms Stocks in her bed. She was not breathing.

Jayden immediately called Ambulance Tasmania, and subsequently paramedics attended the scene along with police officers. Ambulance paramedics later pronounced Ms Stocks deceased.

The attending police officers noted that Ms Stocks was lying clothed on her left side on the bed.

There was a small amount of vomit and blood coming from her mouth and nose, staining the pillow in front of her mouth.

When Ms Stocks’ home and campervan were inspected by the officers, they noted both were in a neglected state. Police attending the scene likened the house to a “hoarder’s home”, with large quantities of rubbish in and around the house. A black backpack was found that contained numerous different medications. Police also found medication prescribed to Ms Stocks

scattered around the home and within the campervan, suggesting that Ms Stocks had been hoarding medications. It appeared that she had not been waiting to finish a packet before refilling a prescription. Though there were several empty blister packs located in the campervan, none were within reach of Ms Stocks. No suicide note was located in the house or the van.

A formal identification was completed by First Class Constable Michael Silk, who knew Ms Stocks from her dealings with police.

A post-mortem examination was conducted by forensic pathologist, Dr Donald Ritchey, on 24 December 2018. Dr Ritchey concluded that death was due to mixed prescription drug toxicity complicating emphysema with active respiratory bronchiolitis. Dr Ritchey noted that the multiple prescription drugs detected in Ms Stocks’ blood were at elevated concentrations and were considered central nervous system depressants. The toxicology results showed the presence of alcohol, tramadol, amitriptyline, codeine, alprazolam, diazepam, and paracetamol. In particular, there were fatal levels of tramadol detected, as well as toxic levels of codeine and amitriptyline. The level of alcohol was very low.

Dr Ritchey stated that, when used in combination with each other, these substances would have caused sedation and unconsciousness followed by cessation of breathing and death by a mechanism of respiratory arrest. Dr Ritchey also noted that as Ms Stocks suffered from lung disease, she was at increased risk of death due to drug-induced central nervous system depression.

I am satisfied that Ms Stocks died from mixed prescription drug toxicity. I am further satisfied, based upon a thorough scene examination by the officers, that there are no suspicious circumstances surrounding her death. There is no evidence that she deliberately intended to end her life by an overdose of medication. I find that her death was accidental and due to her taking an excess of medication. No one saw her take the medication, which she likely ingested during the day and/or evening before she was helped into the bed of the campervan. It is not possible to find the actual quantities of medication taken, although the blister packs found at the scene indicated that she took her prescribed medication in a haphazard, rather than orderly, manner.

Upon the evidence, I am satisfied that the medication ingested by Ms Stocks was prescribed to her by Dr Q, with the exception of the alprazolam, which she may have retained from her mother’s past prescriptions.

Comments and Recommendations One matter for comment arising in this investigation is whether Dr Q exercised appropriate diligence when he resumed Ms Stocks’ prescriptions for multiple pain medications immediately after her return from Queensland.

I therefore sought a review from Pharmaceutical Services Branch concerning any issues pertaining to these prescriptions, which on the facts of the investigation, provided Ms Stocks a ready supply of a large quantity of potent medications.

PSB is responsible for administering the Poisons Act 1971 and records the supply by pharmacies to patients of Schedule 8 narcotic substances. As such, PSB recorded the supply by Dr Q to Ms Stocks of her prescribed narcotic medications, primarily oxycodone, as well as the authorities provided by PSB to Dr Q to enable the supply. On 17 December 2018, Dr Q applied to PSB for authority to prescribe the medications to Ms Stocks and the authority was granted.

In the report from the PSB, Acting Chief Pharmacist, Mr Sam Halliday, stated that Ms Stocks’ medication included a combination of sedating and psychotropic medications – including multiple opioid analgesics, multiple benzodiazepine, pregabalin, high-dose amitriptyline, sumatriptan and metoclopramide.

He noted that this is to be considered a high risk and potentially dangerous regimen in the absence of thorough clinical assessment and implementation of clinical risk mitigation strategies.

Mr Halliday said that the responsibility upon Dr Q was to ensure that he had conducted a risk benefit assessment of such prescribing with appropriate clinical safety measures in place regarding the proposed prescribing regimen.

After reviewing the evidence in the investigation, Mr Halliday formed the following conclusions:

1. Dr Q did not undertake a sufficient risk-benefit assessment of the prescribing regimen before issuing the prescriptions to Ms Stocks in December 2018, just before her death.

2. Dr Q did not communicate with any doctors in Cairns regarding Ms Stocks’ relevant and recent medical history or prescribing issues in the previous 12 months. Instead, he relied upon a letter which did not contain medical letterhead, presented to him by Ms Stocks, without taking further steps to confirm whether the letter was actually authored by her treating medical practitioner. Further, he did not take possession of this letter and apparently did not contact the Queensland Department of Health’s Drugs of Dependence Unit to confirm the details of any supplies of Schedule 8 medicines in that jurisdiction. Mr Halliday made subsequent inquiries with that Unit, which indicated that Ms Stocks had never been dispensed Schedule 8 medicines in Queensland.

3. Dr Q had an unrealistic expectation of the role of PSB in the assessment of a patient’s prescribing regimen. He appeared to assume that where an authority had been granted by a PSB delegate, the doctor may take less responsibility for consideration of contemporary medical evidence, current practice guidelines or in the conduct of a full risk-benefit assessment. Mr Halliday notes in this regard that PSB pharmacists are not registered doctors nor in a position to directly assess and manage patient care. It is the general practitioner who carries the primary responsibility for patient care.

Mr Halliday concluded that if a more thorough clinical due diligence process was carried out by Dr Q then Ms Stocks may not have had available to her a significant supply of a combination of high risk medicines. For example, further consideration may have caused Dr Q to require staged supply to Ms Stocks. Additionally, if he had sought and received advice that Ms Stocks had not been prescribed any Schedule 8 substances in Queensland, it is likely that he would not have prescribed the OxyContin (oxycodone) at this time and may have been more circumspect in prescribing the other medications in the high risk combinations. Similarly, if he had sought the advice of a relevant specialist, he may also have limited his prescribing to safer substances and quantities.

I conclude that Dr Q should have exercised more caution, knowing that he had not treated Ms Stocks (a patient with a complex medical and pain history), for the past 12 months and had no independent information concerning her situation during that time.

In making these comments, I acknowledge that Ms Stocks was, in any event, a person at risk of an overdose by the manner in which she both hoarded medication, did not take medication as directed and used her mother’s medication. She may therefore have died of a fatal overdose regardless of the prescribing deficits I have outlined.

I have received helpful explanations from Dr Q explaining the rationale for his prescribing to Ms Stocks. He stated in his report that, on the first occasion that Ms Stocks re-presented to him on 10 December, he spent an hour with her, instead of the allocated 10 minutes, attempting to consider her medication requests and attempting to rationalise and reduce her medications. Dr Q reported that Ms Stocks presented in a polite and friendly fashion and he had “no particular anxieties about continuing her usual medications” as they were effectively identical to her established regime during her previous life in Cygnet. He said that she did not display any signs of drug seeking behaviours, intoxication or emotional issues. She had also indicated to Dr Q that a similar or increased medication regime had been in place for her in Queensland. Dr Q also took the step at that stage of discussing the prescription regime with the pharmacist and to make preliminary telephone contact with PSB to check if there were any

barriers to prescribing from its point of view. Dr Q said that both he and the pharmacist were reassured by PSB that there were no prescribing barriers.

Dr Q also stated that, after the first consultation, he recognised that he needed to have further time with Ms Stocks to “sort out” both her and her children’s medication issues. He said that when he saw Ms Stocks for the second appointment for this purpose on 14 December it was unexpectedly dominated by other medical issues. He then intended to make a third appointment to finalise her medication regime but she passed away before that could occur. He said that communicating with Ms Stocks’ general practitioner in Queensland was one of a number of issues that he intended to address in due course. It seems clear to me that Dr Q was under considerable time constraints in his practice, but still managed to give Ms Stocks as much consultation time as possible.

Dr Q also emphasised in his reports that he had known Ms Stocks and her mother since Ms Stocks was a child. He had been to their house on many occasions and had seen no sign of illegal drug taking. He said he had never seen her intoxicated or under the effects of illicit drugs.

There is no evidence that Dr Q was aware of her inconsistent practices of taking her prescribed medications.

Dr Q accepted the validity of the comments made by the Acting Chief Pharmacist and did not seek to dispute those matters. He has now retired as a medical practitioner. I fully accept that Dr Q did his best at the time to attempt to prescribe safely to Ms Stocks, a long term patient.

He was a general practitioner dedicated to the service of many patients and, in this case, it is understandable that time pressures and a desire to assist her symptoms resulted in a decision to prescribe without taking all of the steps required to ensure that risk was minimised.

Finally, it is relevant to observe that Ms Stocks was well aware of the requirement to take her numerous medications as prescribed, and was well aware of the risk of toxicity in the event that she did not do so. She was ultimately responsible for her own safety.

I extend my appreciation to investigating officer, First Class Constable Michael Silk, for his investigation and report.

I convey my sincere condolences to the family and loved ones of Ms Stocks.

Dated: 10 May 2021 at Hobart Coroners Court in the State of Tasmania.

Olivia McTaggart Coroner