A 20 month year old male died on 24 August 2013. He was found lying in his bed, cold and unresponsive. The cause of death was found to be ingestion of oxycodone located in his household.
There was determined to be insufficient evidence to explain how the drug was ingested. In the month prior to his death, 560 oxycodone tablets were prescribed to the child's grandparents by a local general practitioner.
Background Facts
The 20 month year old aboriginal male, referred to as 'the child', was born on 3 December 2011 to first time parents. The parents had already separated by the time of the child's birth.
The child lived with his mother at a four bedroom house in Cairns. The mother and child shared one of the rooms, with other regular occupants of the home being the child's maternal grandparents, a maternal aunt and a family friend. It was not unusual for the child to be left in the care of his maternal grandparents for several days at a time. An informal arrangement existed between the broader family in relation to shared time with the child.
On the morning of 24 August 2013 at approximately 11:30am, the child was found by his grandfather lying on his left side in the middle of the bed, on top of the bedlinen with his mouth towards the top of the bed. The child was non-responsive and cold to touch.
Queensland Ambulance Service (QAS) was called around 12:05pm. Officers promptly arrived at the home and observed the grandfather performing CPR on the child in the lounge room under the guidance of the QAS operator. QAS officers attempted CPR but were unable to revive the child. The child was pronounced deceased at approximately 12:25pm.
Prior to his death, the child was in good spirits despite an existing cold, which had symptoms of a runny nose and occasional cough. Occupants of the house indicated that the symptoms of the cold had not prompted concern. The child was under the care of his maternal grandparents as his mother had left to visit friends on Friday 23 August 2013. The child spent the day at the lagoon with his maternal grandparents, later falling asleep for a nap around 4:00pm before eating dinner with his maternal grandparents, aunt and the family friend around 7:00pm.
After dinner, the child was reportedly kicking a ball and playing pushbike with his maternal aunt and grandparents. He was still awake when his grandmother returned around 9:00pm. The child was reported to have fallen several times whilst playing, however this was suggested by the occupants of the household to not be unusual. There was nothing to suggest a significant fall in the post-mortem evidence. The child resisted bed-time and was put to sleep between 11:30pm on Friday evening and 2:30am on Saturday morning. The child was put to sleep by the maternal grandfather who had read him a book.
The child was not seen until the following day, and none of the household occupants reported that he had woken during the night. The maternal grandfather checked on the child around 8:30am on Saturday morning and left him with a bottle of chocolate milk. It was a common occurrence for the child to be left with a bottle in the morning and then doze off. The maternal grandmother reported that she observed the child that morning giggling under the blanket, with one arm over the top. This is the last time the child was observed before being found unresponsive by his maternal grandfather at approximately 11:30am.
The maternal grandparents were the only people home when the child's body was discovered.
Findings
It was found that the child died from lung infection consequent to oxycodone intoxication.
The post-mortem findings included:
- lung infection with evidence of inhaled food material;
- inflammation of the lining of the voice-box region; and
- oxycodone at a concentration of 3.6mg/kg in the child's blood, a level which is lethal to adults.
Although the congestion and lung infection may be responsible for the death, the significant and unexpected presence of oxycodone in the blood found through toxicological analysis was considered to have exacerbated the symptoms of the lung infection, resulting in death. The means of which the oxycodone was ingested by the child was not found. It was considered that the occupants of the household were also unaware of the means in which the child had ingested oxycodone.
The amount of tablets consumed to reach the 3.6mg/kg oxycodone blood concentration could not be accurately determined, yet it was likely to be extraordinarily high. The high concentration found in the child's serum was within the lethal range for adults and would similarly be fatal to children. The maternal grandparents were both found to have been prescribed an unusually large number of prescriptions for oxycodone. In the month prior to the child's death, the grandfather had been prescribed oxycodone on nine occasions, and the grandmother on eleven occasions. 560 oxycodone tablets were prescribed in total by Dr Sanouiller in this period. It was found that over the past year the grandparents had received excessive prescriptions for oxycodone from Dr Sanouiller. The maternal grandparents kept the oxycodone stored in a safe in their room and sometimes transferred into a 'days of the week' tablet dispenser. The grandfather conceded that it was possible that the child found some oxycodone and ingested it, given the large quantity that was coming into the house. There was no evidence to suggest that the child was subject to any harm. This was made with consideration that the child was known to child and safety services.
Dr Sanouiller was subjected to prohibitions on obtaining, administering, dispensing or prescribing Schedule 8 controlled drugs and Schedule 4 restrictive drugs as a consequence of his over-prescription to the child's maternal grandparents. Dr Sanouiller's registration as a general practitioner has since expired.
Recommendations
Real time prescription monitoring should be implemented as a matter of urgency to prevent 'doctor shopping' and so that the quantity of drugs in an individual's possession can be determined at any time.
Further inquiry
Real time prescription monitoring is planned to be released in Queensland with the Medicines and Poisons Bill 2019.
