An issue in a recent New South Wales coronial investigation was whether the stresses and pressures of a College training program contributed to the death of a trainee.
The Coroner concluded that other factors were responsible for the death. The Coroner concluded there was no evidence to suggest that participation in the College training program, or any aspect of it, directly contributed to the death.
In findings published 24 November 2016, the New South Wales Coroners Court investigated the circumstances of the 2013 death of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainee Dr Beata Vandeville. The report concluded that Dr Vandeville’s death was the result of an accidental overdose.
Deputy State Coroner Derek Lee also made some comments regarding the regulation of access to restricted drugs in hospitals, particularly access to the anaesthetic drug propofol.
When a person’s death is reported to a coroner, the coroner has an obligation to make findings in order to answer questions about the identity of the person, the location and time of death, and the cause and circumstances of the death.¹
The Coroner noted that the main issues at hand in the investigation were the cause of death, how restricted substances came to be found in Dr Vandeville’s home, how said substances were found in her system post-mortem, the events surrounding the discovery of her death on 18 January 2013 and the nature and circumstances of her enrolment at the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (“the College”) Training Program (and whether it in any way contributed to her death).²
The Coroner remarked that Dr Vandeville had been described as a “gifted and skilled” surgeon, a “dream” of hers which she would sadly never realise.³
Cause and circumstances of the death of Dr Vandeville
In the days preceding her death, evidence showed that Dr Vandeville was bedridden with a temperature and low blood pressure. Dr Kapir had suggested that she go to hospital but she refused.4 Subsequently, she was “home hospitalised” by Dr Kapir using antibiotics and pain relief medication.5 Dr Kapir found Dr Vandeville unresponsive on 18 January 2013 in her Sydney home.6 He performed CPR on Dr Vandeville, calling emergency services some two hours later.7
The Coroner concluded that: Dr Vandeville self-administered substances which led to an accidental overdose and her subsequent death.8 Among others, the drugs found in her system post-mortem included propofol, midazolam, fentanyl and alfentanil (all of which are used in anaesthetic procedures).9 However, there was insufficient evidence to demonstrate that she had intended to end her life, despite some threats of self-harm and suicide in the past and ongoing troubles with her mental well-being at the time.10
Additionally, the Coroner found that whilst Dr Vandeville had made attempts to obtain restricted substances during various hospital-based training placements, the drugs involved in her death were supplied by her fiancé, despite his denying that this was the case.11 The Coroner concluded that Dr Kapir, as an anaesthetist, would have had been able to access the drugs, albeit with some difficulty.12 It would have been highly unlikely for Dr Vandeville to have done so.13
Dr Vandeville’s medical training
Dr Vandeville was in the process of undergoing specialty training at the College at the time of her death.14 After four years in the program, Dr Vandeville failed multiple attempts at an exam over the 2010 to 2012 period.15 Evidence demonstrated that she was often unwell and stressed during this period, and had been critical of how her assessments had been conducted.16
Dr Vandeville had expressed several concerns and dissatisfaction with aspects of the training program, and with the overall examination process. The College granted several requests for extension of time and gave additional feedback sessions to address her concerns. She was allowed five attempts to sit the oral examinations, where the College would typically only allow four attempts.
The Coroner also considered Dr Vanderville’s practical training in the work place and rejected suggestions that this had contributed to her death.
However, the Coroner found that no aspect of Dr Vandeville’s participation in the training program of the College directly contributed to her death.17 He concluded that the College exceeded the obligations it owed to Dr Vandeville following her failed assessments (such as granting more feedback sessions and more opportunities to sit the examination than were provided for by College policy).18
Recommendations regarding access to restricted drugs in hospitals
Mr Lee made some remarks regarding the unauthorised diversion of drugs and restricted substances from hospitals.19 Coroners may make recommendations in relation to any matter regarding the person’s death, and issues of public health and safety often form the subject of these recommendations.
Mr Lee noted that the unauthorised diversion of drugs and restricted substances from hospitals was not a novel issue, and that the diversion of propofol and its misuse has become a general problem in recent years, particularly in the medical community.20
Mr Lee referred to the current recommendations set in place by the Department of Health (“the Department”) and the Australian and New Zealand College of Anaesthetists (“ANZCA”) as adequately balancing patient safety with the need for safe and secure storage of drugs of anaesthesia.21
He referred to submissions that the drugs had to be readily accessible in order to prevent delay in administration to patients under anaesthesia in order to avoid potentially catastrophic implications, as well as the need for drugs to be stored securely so as to prevent unauthorised procurement.22 The coroner did not however make formal recommendations regarding this.23
Implications for Medical Colleges
This case raises a number of issues for consideration by Colleges:
- Monitoring the stress and pressures for trainees in being part of the training program and facing significant examination pressures. Most Colleges will have a health and wellbeing policy with appropriate clinical support where trainees are in need of assistance.
- Access to drugs, particularly drugs of dependence, is a critical issue for some medical Colleges. Special policies and monitoring approaches should form part of these policies. Reference to the policies of the Medical Board of Australia and MCNZ may assist.
- Warning signs of poor wellbeing for trainees should include multiple failed attempts at examinations, consistent poor performance in training, multiple complaints or expressions of concern which may hide undue stress, irrational behaviour or responses.
- This is not first time where the death of or injury to a trainee has been raised in the context of overwork and unsafe work hours. The “safe work hours” campaign has addressed some of these issues, although it is not always confirmed in practice in all hospitals. It is a wellbeing issue for Colleges to ensure that the safe hours program is in place for its trainees.