CORONERS COURT OF QUEENSLANDFINDINGS OF INQUEST CITATION:Inquest into the death of Michael JamesCalder TITLE OF COURT: Coroners CourtJURISDICTION: BrisbaneFILE NO(s): 2014/2468DELIVERED ON: 2 September 2016DELIVERED AT: BrisbaneHEARING DATE(s): 15 April 2016, 16 -18 August 2016FINDINGS OF: John Lock, Deputy State CoronerCATCHWORDS: Coroners: inquest, health care related death,private hospital admission, headache, concurrentprescription of slow release and fast acting opiatemedication, death due to opiate toxicity,communication and documentation betweendoctors and nursesREPRESENTATION:Counsel Assisting: Ms M JarvisCalder family: Ms A Martens, Maurice Blackburn LawyersDr R Brockett: Ms K Mellifont QC i/b Avant LawHoly Spirit Northside PrivateHospital: Ms J Rosengren i/b Minter EllisonNurse Meadowfair: Mr B Hall i/b Creevey RussellFindings of the inquest into the death of Michael James CalderContentsIntroduction 1Issues for Inquest 1Autopsy results 2Medical and Nursing care provided over 8 to 10 July 2014 ..3Evidence of Dr Rodd Brockett ..8Root Cause Analysis ..11Expert Review by Dr Charles Denaro 15Expert Report by Dr Peter Lavercombe 17Conclusions on the Issues ..19Cause of Death 20Appropriateness of the health care provided .20Findings required by s. 45 22Identity of the deceased ..22How he died ..22Place of death ..23Date of death 23Cause of death 23Comments and recommendations ..23Findings of the inquest into the death of Michael James Calder Page 1Introduction1. Michael James Calder was aged 33. Michael and his partner, Andrea Younghad three young sons together. Andrea described Michael as having a greatsense of humour and fun. He was a caring and very engaging father to his sons,and a loving partner, son and friend. His loss in these tragic circumstancesremains raw for his family and friends.2. Michael was referred by his GP to the Holy Spirit Northside Private Hospital(HSNPH) on 8 July 2014. He had a three day history of severe occipitalheadaches which were throbbing in nature and continuous. He also developedneck pain and stiffness with increasing severity of his headache. He was notedto be febrile. The GP referral letter noted he had similar symptoms four yearspreviously when he was diagnosed with viral meningitis. It is now known thatMichael also had a history of obstructive sleep apnoea, which had been treatedat the same hospital. This history only became known to those treating him afterhe died.3. Whilst in the HSNPH Emergency Department a number of tests wereperformed. He was given analgesia including IV morphine 10mg in total. He wasthen admitted to the ward under Dr Rodd Brockett, a specialist generalphysician.4. During the course of his ward admission Michael received analgesia for theongoing headache including subcutaneous morphine, oxycodone, Ordine (liquidmorphine), MS Contin (slow release morphine), Gabapentin (neuropathic pain)along with paracetamol and ibuprofen.5. Two early doses of morphine were given intravenously (10mg) on 8 July and bysubcutaneous injection (5 mg) on 9 July 2014. The remaining doses were in oralform. Over time the doses and dose frequency of opiate analgesia increased forhis ongoing pain.6. Nursing notes indicate Michael was regularly checked on by nursing staff andthere were no obvious signs of narcotisation and when asleep he was breathingnormally. Subsequent retrospective reviews of the medical records indicatedevidence of deterioration in his respiratory function including low oxygensaturations. Around 04:40 hours on 11 July 2014 Michael was found to beunresponsive and in cardiorespiratory arrest. CPR was performed however hewas unable to be resuscitated and was pronounced deceased at 05:17 hours.Issues for inquest7. Michaels death was reported to the coroner by Dr Brockett because it wasunexpected and the cause uncertain. An initial review of the medical recordsperformed by Dr Adam Griffin of the Clinical Forensic Medicine Unit consideredthe circumstances of his sudden and unexpected death indicated a probablecontributory factor was the level of opiate medication that was being provided tohim in hospital. Subsequent autopsy examination found the cause of death tobe due to opiate toxicity.8. During the coronial investigation statements were obtained from the admittingphysician, Dr Rodd Brockett and nursing staff. An independent expert reportwas obtained from Dr Charles Denaro who also expressed concern about theprescribing regime of pain medication and in particular the levels of slow releaseand fast acting oral morphine utilised in this case. The hospital also conductedFindings of the inquest into the death of Michael James Calder Page 2a Root Cause Analysis. As a result, a number of systemic recommendationswere made and the Hospital provided details of the implementation of thoserecommendations.9. As there continued to be some uncertainty about the precise circumstanceswhich brought about Michaels death, a decision was made to hold an inquest.On 15 April 2016 at a pre-inquest hearing, the following issues for the inquestwere determined:a. The findings required by s. 45 (2) of the Coroners Act 2003; namelythe identity of the deceased, when, where and how he died and whatcaused his death.b. The circumstances leading up to the death.c. The appropriateness of the health care provided to the deceased atthe Holy Spirit Northside Private Hospital from his admission on 8 July2014 and up until his death.The following witnesses were called to provide evidence.? R.N. Greecezel Goudswaard? R.N. Belinda Lewis? R.N. Courtney Roach? R.N. Sunshine Juan? EEN Maryann Meadowfair? R.N. Shelly Taylor? R.N. Marie Ballinger? Dr Rodd Brockett? Dr Charles Denaro? Dr Peter LavercombeAutopsy results10. A full internal post-mortem examination was conducted by Dr Nadine Forde,Forensic Pathologist. Dr Forde found some mild swelling of the brain but therewas no obvious cause of death. The lungs were heavy and there were moderatepleural effusions and histological evidence of acute aspiration pneumonia.11. Toxicology analysis was performed on admission blood (i.e. blood taken onadmission to the ED and before any medications were provided). Diazepam,sertraline and Ritalin were detected at non-toxic levels in the admission blood.Morphine and other opiates were not detected in admission blood.12. Toxicology was also analysed on post-mortem femoral blood. Post-mortemblood levels found Gabapentin, ibuprofen and paracetamol, Ritalin, sertralineand diazepam in therapeutic or non-toxic ranges. Oxycodone was detected inabove therapeutic but below toxic ranges. Morphine was found well within thelethal range.13. The pathologist noted that morphine levels can be difficult to interpret as thereis overlap between therapeutic and toxic/lethal levels. This is because individualresponses can vary greatly, particularly in the setting of chronic use. However,it was also noted that Michael had no history of regularly taking such medicationand there was no evidence of narcotic analgesia in his blood at the time of hisFindings of the inquest into the death of Michael James Calder Page 3admission. Given his apparent lack of previous exposure to regular narcoticanalgesia the pathologist opined he would have been more susceptible to itseffects than an individual with more regular exposure.14. The pathologist opined that the cause for his headache remains unclear and thepossibility of resolving viral meningitis cannot be excluded, although otherpossibilities may include musculoskeletal pain or migraine. There were noautopsy findings to suggest that death occurred as a result of these.15. There was evidence of acute pneumonia. His initial presentation to hospital didnot fit with that of lower respiratory tract infection. Whilst in hospital there wereno features, including an increase in respiratory rate clinical findings, suggestiveof pneumonia. There was clinical evidence of reduced oxygen saturationsrequiring oxygen therapy at 08:00 hours on 10 July 2014. There were somesmall fragments of foreign material in the lungs and the findings and clinicalhistory are suggestive of an aspiration event, possibly occurring around the timeof this fall in oxygenation.16. The level of morphine fell well within the range considered to be potentiallylethal. Oxycodone is also an opioid analgesic, and whilst the level of oxycodonewas below that considered to be toxic, its actions are similar to that of morphineand the effects would have been additive with the morphine.17. The development of aspiration pneumonia was most likely caused due to theopiate effect causing a reduced level of consciousness impairing his ability toprotect his airways.18. The pathologist considered the death has occurred as a result of opiate toxicity,from both the combined effects of aspiration pneumonia and the immediate toxiceffects of opiates on the central nervous system and respiration.Medical and nursing care provided over 8 to 10 July 201419. Michael had a medical history of anxiety and previous viral meningitis in 2011.In 2009, sleep studies showed him to have severe obstructive sleep apnoeasyndrome for which he received surgical treatment at Holy Spirit NorthsidePrivate Hospital. He was prescribed medications by his GP including Valium(diazepam) and Zoloft (sertraline), medications commonly used (as well as forother conditions) for treatment of anxiety.20. Michael presented to the HSNPH Emergency Centre (ED) at approximately14:40 hours on 8 August 2014. A provisional diagnosis of viral meningitis wasmade. A lumbar puncture was performed, which noted clear fluid and noelevation of white cell count. A CT head scan was normal with no evidence ofintracranial haemorrhage. Other testing was unremarkable. Michael wascommenced on anti-viral medication when he first presented to the ED. He wasgiven analgesia and provided with IV morphine of a total of 10mg over a halfhour period.21. Michael was then admitted to the ward under Dr Rodd Brockett, generalphysician. At the time of admission unusually a Patient History form was notcompleted and hence a question contained on the form as to whether Michaelsuffered or ever suffered from sleep apnoea was not answered. A referral letterfrom the ED was provided and there was a discussion with Dr Brockett. As wellthe ED record was provided. It is apparent the ED is a separate entity to theFindings of the inquest into the death of Michael James Calder Page 4HSNPH. This ED record routinely was not considered by Dr Brockett due to itsdifficulty in being sensibly or easily digested and read. Dr Brockett was notaware of a previous history of sleep apnoea and did not read the entry in the EDrecords that at 19:20 hours in the ED there was an episode when Michaelsoxygen saturations plummeted to 79% but rose on rousing.122. Michael arrived from the ED at around 20:15 on 8 July 2014. It is instructive tonote that at the time nursing staff recorded vital signs observations in a ModifiedEarly Warning Score (MEWS) chart. This chart complied with the AustralianCommission of Safety and Quality in Health Care National Standards. The chartis said to be a tool to assist in the recognition of a deteriorating patient.Relevantly, in respect of oxygen saturations the MEWS chart provided asfollows:i. If oxygen saturations fell between 87% and 92% they were toadminister oxygen. If saturation levels continued to fall withincreasing shortness of breath they were to inform the teamleader immediately; ii.If saturation levels fell below 86% they were to apply oxygenand inform the Team Leader who will inform the treatingDoctor;If saturation levels fell below 80% they were to apply oxygeniii. via a non-rebreather bag and institute a MET call. If theycontinue to drop or the patient does not respond to oxygentherapy they are to call a CODE BLUE.23. Endorsed Enrolled Nurse (EEN) Maryann Meadowfair was involved in the careof Michael during the night shifts of 8, 9, 10 July 2014. She first provided astatement to the hospital at 08:20 hours very shortly after the death and herstatement to the coroner was dated 31 July 2014. EEN Meadowfair wassubsequently dismissed from her employment, it seems as a result of whatoccurred. EEN Meadowfair was a very experienced enrolled nurse andunderstood her limitations to practice, particularly regarding medications andthe hospital policies.24. EEN Meadowfairs shifts commenced at 22:00 hours and concluded at 07:00hours. On each of the night shifts her patients included Michael in bed 19. It isapparent that during the night shift EEN Meadowfair had a patient load of about10 patients. There were two other registered nurses rostered on the ward witha similar patient load. The day and afternoon shifts were rostered somewhatdifferently in that two nurses were allocated 10 patients cared for as a team orbuddy nursing system.25. On the Tuesday of 8 July 2014, EEN Meadowfair recalls Michael had a lot ofheadaches and she gave him pain relief. His neck and back were sore and hestated that his head was pounding. She says in her statement that duringhandover he was admitted for viral meningitis, which he had previously in 2011,and a history of anxiety and sleep apnoea. In her evidence EEN Meadowfairwas less certain about knowledge of the history of sleep apnoea and stated thiswas really a Query? about sleep apnoea. R.N. Juan gave evidence that on 9July she asked Michael if he had a history of respiratory difficulties such as sleepapnoea and received a negative response. It is probable that the respiratorydifficulties including the possibility of sleep apnoea were discussed amongst1 This information was not referred to in the referral letterFindings of the inquest into the death of Michael James Calder Page 5nursing staff and it is in this context that EEN Meadowfairs query about sleepapnoea was considered. It is fair to say the history of previous treatment for anddiagnosis of sleep apnoea was not evident to treating staff, including DrBrockett, until after the respiratory arrest.26. It may be important to acknowledge at this point that Michael had previoussurgery to alleviate the symptoms of sleep apnoea at the same hospital. It isapparent that the previous hospital admission records did not becomeimmediately available on the ward as should have occurred.2 As well, it wasconsidered likely that Michael (similarly to other persons receiving thistreatment) may have mistakenly thought the surgery cured him of sleep apnoearather than alleviating some of the symptoms such as snoring. This may havebeen the basis for his negative response to the inquiry by R.N Juan.27. R.N. Greecezel Goudswaard was involved in the afternoon shifts of 9 and 10July 2014 from 14:00 hours until 22:30 hours. She made a note in the progressnotes towards the end of her shift on 9 July 2014 that Mr Calder was alert andcoherent, mobile and self-caring and his observations were stable and he wasafebrile. He continued to make complaints of a severe headache and she notedshe had given him pain relief for this with some effect. She gave him 40mg ofOrdine at 05:15 and says this must have been on the basis that his pain was atthe more severe end. The records note she took a number of observations,which are recorded in the observation chart and provided medication. Hisoxygen saturations were 95% on room air with other vital signs all within normalrange. R.N. Goudswaard said she does not recall any discussions with DrBrockett about Michaels condition or treatment plan and medications on any ofher shifts. She said some doctors will speak to the nurses or the team leaderwhile others will write the orders up in the chart.28. On the night shift of Wednesday 9
July 2014, EEN Meadowfair thought Michaelseemed a lot brighter although he still had headaches. She made no mention inthe progress notes as to the level of pain and agreed with hindsight it wouldhave been prudent to do so.29. R.N. Courtney Roach was rostered on the morning shift of 10 July 2014commencing at 06:30 hours until 15:00 hours. She recalls she was working witha buddy nurse R.N. Xie Juan . She is uncertain as to whether it was R.N. Juanor herself who administered 40mg OxyContin at 07:15 hours, although hersignature is in the medication book. R.N. Juan recalls it was herself.30. Prior to 07:50 hours R.N. Roach recalls R.N. Juan speaking to her regarding theprescription for Ordine. R.N. Juan was concerned that the order in the chart didnot specify a frequency or maximum dose. Together they noted that the lastdose had been given to him at 04:30 hours and they wanted to check whetherit could be administered third hourly. Hospital policy required that all telephoneorders must be communicated to two nurses. A telephone call was made byR.N. Juan to Dr Brockett and he confirmed it was to be third hourly and shebelieves that R.N .Juan wrote that in the chart and she co-signed. R.N. Juangave Mr Calder another 20mg dose of Ordine at 07:50 hours. R.N. Juan saysshe intentionally kept the dose at the lower end of the ordered range as she was2 The evidence of Ms Ravn is that by interrogating the HSNPH clinical information system it seems theprevious medical records were requested at 09:10 hours on 9 July 2014 and were in the ward by 10:56hours. It remains unclear where the records were kept during 9 and 10 July but they were certainlypresent when Mr Calder was found unresponsive.Findings of the inquest into the death of Michael James Calder Page 6not aware of Mr Calders need for or response to pain medication and she notedthat he had also been given OxyContin (slow release) at 07:15 hours.31. R.N. Juan performed observations at 08:00 hours on 10 July. Prior to this shenoted his oxygen saturations were 85% to 88%. She recalls the oxygen probealarmed at 85% when she first placed the probe on his finger but stabilised at88% after a few seconds. She stated she applied oxygen but cannot recallwhether she started with 1-2 L and increased to 3 L, but at 3 L his saturationscame back to 92%. The formal recording of oxygen saturations at 08:00 hourswas 88%. She recalls Mr Calder was surprised when advised that he neededoxygen. She recalls she was also surprised by the reading because clinically heappeared fine. She asked if he had any respiratory problems such as sleepapnoea and he said no. She recalls mentioning to R.N. Roach that the oxygensaturations had been low.32. She returned to Mr Calders room to check on his pain relief and to ensure hisoxygen saturations remained acceptable. At 10:00 hours he advised hisheadache was as bad as it had been earlier and she gave him a further full doseof 40mg of Ordine. His oxygen saturations remained acceptable. Later she wentto check on him again after the second dose and he was walking around andhe said the headache had improved a little. She administered a further dose of40mg Ordine at 13:40 hours as he had requested further pain relief. Each timeshe saw Mr Calder on the ward he was speaking clearly and did not seemdrowsy.33. R.N. Roach recorded his observations at 11:30 hours with his temperature 36.9,blood pressure 115/68, pulse 97, respiratory rate 18, oxygen saturations 93%and he was on 2 L of oxygen. She cannot remember the pain score as she didnot record it. It is now her practice to record pain scores for each patient but atthe time her usual practice was to ask but not necessarily record it every time.34. R.N. Roach recalls Michael was awake but tired. He was in pain and wanted theroom dark. She administered his regular midday 1g paracetamol and 400mgibuprofen. She noted that prior to handover Dr Brockett had recently attendedand made new medication orders, so she completed the times when the regularmedication was to be given. She stated it was not unusual for doctors to notspeak to the nurses about changes in medication or treatment and they wouldeither speak to a team leader or write in the progress notes.35. R.N. Greecezel Goudswaard also cared for Michael on the afternoon shift of 10July 2014. R.N. Belinda Lewis was her buddy on the shift. R.N. Lewis tookobservations at 16:30 hours. Michaels temperature was 37.7, BP 120/72, pulse100, respiratory rate 18 and he was on 2L oxygen via nasal prongs. She did notrecord his oxygen saturations but said with the machine on, it would havealarmed if it went below 90%. He complained of severe pain but she did notrecord it. She gave him 40mg Ordine at 16:45 hours as well as paracetamol andgabapentin at 18:00 hours. She recalls Michael kept taking off his nasal prongsas he found them irritating. He sounded coherent and was not slurring his words.36. R.N. Goudswaard recalls that Michael remained troubled by headaches butwas alert, coherent and conversing appropriately. In her statement she said hedid not appear particularly drowsy and was not slurring his words. She wasunable to explain the choice of word particularly and re-iterated he was notdrowsy. He did not appear to be in any way confused. She gave Mr Calder MSContin, ibuprofen and Movicol at 20:00 hours. The Doctor had ceasedFindings of the inquest into the death of Michael James Calder Page 7OxyContin earlier that day and replaced it with 80mg MS Contin twice daily. Shegave Mr Calder his first tablet of MS Contin at 20:00 hours. She also gave him400mg ibuprofen and his second dose of gabapentin. She performedobservations at 20:30 hours with temperature 37.1, BP 130/84, pulse 102,respiratory rate 20. She noted there had been a slight rise in his respiratory rateand heart rate but they were within an accepted range and he was not exhibitingany significant symptoms. At no time did Michael show signs of narcotisation.Unfortunately, she did not record his oxygen saturations and whether he wason room air or 2L nasal prongs. There were no oxygen saturation readingsrecorded for two observations and she was unable to say why that was. Sherecalled Michael kept taking his oxygen nasal prongs off and had to remind himto put it back on. She also recalls checking his oxygen saturations and with theoxygen probe on it would have alarmed if they went below 90% and this did notoccur. She noted in the progress notes that his severe headache remained +++but was unable to explain how this reconciled with the fact she recorded thepain score on the observation chart as 0. She handed over to EEN Meadowfairbut cannot recall the substance of the handover.37. When EEN Meadowfair commenced her shift on 10 July 2014 she recalls thatMr Calder was a lot brighter but still had the headaches and he had been put ondifferent pain medication. She recalls checking on and recording observationsof Mr Calder around midnight. Upon entering his room she recalls he was in adeep sleep and could hear him snoring loudly through the closed door. She wasunsure why the door was closed and presumes he asked for it to be shut. Shecould not recall if she woke Michael. She checked on him again at 02:00 hoursand he was asleep and snoring very softly.38. EEN Meadowfair stated that they were doing hourly roundings but she cannotrecall if she checked in on him in the period between 02:00 and 04:00.EENMeadowfair said it was her practice to place patients on oxygen if theirsaturations went at or below 90%. She agreed the fact she placed him onoxygen was not recorded in the observation charts. At 24:00 she noted thesaturations were 90% on room air but there is no notation anywhere that sheused nasal prongs to introduce oxygen. Her version which was used to completeher statement was recorded within hours of the tragic events and also makesno reference to oxygen being supplied.39. When EEN Meadowfair entered at 04:40 to check on Mr Calder and to do hisobservations, there was no snoring and she thought he looked different. Sheput a light on and noticed he looked pale and she hit the CODE BLUE cardiacarrest buzzer on the wall. She cannot recall the exact timing of events but hasbeen informed the buzzer was hit at 04:41 hours.40. R.N. Marie Ballinger had not been providing primary nursing care for MichaelCalder. She heard the emergency call at around 04:40 hours and immediatelywent to room 19 where EEN Meadowfair had hit the emergency buzzer. Onentering the room she saw EEN Meadowfair using voice commands to MrCalder to determine if he was conscious. He appeared very pale and lifeless.41. R.N. Ballinger commenced CPR. R.N. Shelly Taylor entered the room and R.N.Ballinger instructed her to bring the cardiac arrest trolley. R.N. Ballinger theninitiated cardiac compressions. She inserted a Guedels airway to assist withairway management and began using the breathing mask in combination withcardiac compressions. R.N. Taylor then assisted in the resuscitation. Sherecalls hooking up oxygen to the air viva bag. She believes they worked on theFindings of the inquest into the death of Michael James Calder Page 8patient for 3045 minutes. Dr Brockett was called in as well as the HospitalCoordinator.42. The arrest team from the ICU then attended the ward and began to lead themanagement of the arrest. The nurses then alternated completing cardiaccompressions and performed other duties as instructed. The resuscitationceased at 05:17 hours.43. Resuscitation efforts lasted for more than half an hour when Dr Brockettdeclared Mr Calder deceased.Evidence of Dr Rodd Brockett44. Dr Rodd Brockett is a specialist physician and intensivist. It is important to recordthat at the inquest Dr Brockett provided an emotional apology to Ms Young andthe Calder family and took responsibility for his practice and the treatmentprovided to Michael, which he now acknowledged was wrong. Ms Young verygenerously thanked him for that apology.45. Dr Brockett provided three statements. In his first statement Dr Brockettdescribed the treatment history. At the time he first saw Michael Calder he hadalready been given 5mg of Morphine subcutaneously and was receiving Endone5mg four times a day. His pain was quite severe and his neck ache was alsosevere. He described a slightly improving photophobia. Dr Brockett appears tohave seen Michael Calder on the ward at some time during 9 July 2014 but atime was not specified. At that time the plan was to continue IV antivirals. DrBrockett noted a ++++ headache.46. Dr Brockett stated that he tried to get on top of the pain by ceasing the regularEndone and changing it to OxyContin 40mg twice daily.47. On 10 July 2014 it was noted that the headache had persisted. Dr Brockettappears to have seen Mr Calder around 11:30 hours on 10 July 2014 noting theheadache persisted, chest clear, IV out and to increase analgesia. Dr Brockettincreased the analgesia by giving him 160mg/day of MS Contin in two divideddoses and continuing as needed dose of Ordine, ceasing the OxyContin andstarting some Gabapentin (Neurontin) at 300mg to load him up with intention ofgoing to a lower dose the next day.48. Dr Brockett had no further contact with or about Michael until he was called at04:44 hours on 11 July 2014 by the on duty nurse coordinator who said Michaelwas in asystolic arrest. He attended immediately and noted the efforts at tryingto resuscitate him but it was agreed that after 30 minutes further continuationwould be futile.49. Dr Brockett disagreed with the initial assessment of Dr Griffin in relation to thechart review. He stated that The Australian Medicines Handbook adopts a scalethat the approximate dose equivalent to 10mg of parenteral morphine is 30mgof oral morphine and 15mg of oxycodone.50. Dr Brockett stated that when he first reviewed Michael sometime between 13:00to 17:00 on 9 July 2014 he had received 10mg IV morphine, 5mg subcutaneousand 10mg oxycodone orally. He stated that this meant he had in the preceding24 hours received approximately 40mg Endone with inadequate analgesia andtherefore he doubled the dose to 80mg baseline Endone equivalent (40mg bdFindings of the inquest into the death of Michael James Calder Page 9of OxyContin) and provided 20-40mg oral morphine (3 hourly as required) ontop of the baseline of the OxyContin, paracetamol and ibuprofen.51. When Dr Brockett reviewed Michael the next day between 11:00 to 12:00 hewas still in pain. In the intervening period he had received 180mg oral morphineand 80mg oral oxycodoneequivalent to 300mg of oral morphine or 100mgparenteral morphine. He ceased the OxyContin and continued the paracetamol,ibuprofens and as needed oral morphine order. He prescribed oral sustainedrelease morphine (MS Contin 80mg bd).52. He states that at no point was there any indication that Michael was receivingtoo much morphine equivalent and he did not believe this was the case. Michaelwas noted on the nursing notes to be bright and alert and therefore he felt hewas not affected by narcotics.53. Dr Brockett provided his second statement shortly prior to the inquest and ashort third statement prior to his evidence. Dr Brockett states that he genuinelybelieved he was acting in the best interest of his patient. Mr Calders death hascaused him to undertake further self-education and to reflect upon his actions.He states that he has reviewed many medical articles and abstracts relevant tothe issue and this review has clearly brought home to him the complexitiessurrounding the variable absorption rates of oral narcotics, as well as thecomplexities of slow release narcotic preparations. There are conflicts within thejournals about some of those issues. He states that this has brought him starklyto the conclusion that he cannot reliably dose slow release narcotics for acutenonsurgical pain and cannot reliably predict the effects of the narcotics on anindividual. He realises that his practice was wrong.54. He states that he now approaches acute pain management very differently. Heis now following a framework that has been developed following substantialdiscussion at the Hospitals Morbidity and Mortality meetings. Essentially thetransitioning to sustained release oral or topical narcotics would only occur oncestable on a steady dose of the patient controlled analgesia. The framework issummarised as follows:i. Regular paracetamol if there are no contraindications;ii. Regular non-steroidal anti-inflammatory drug or COX2 inhibitorif appropriate for the type of pain and if there are nocontradictions to the use;iii. Patient-controlled analgesia with either fentanyl or morphine ifacute pain which would be postoperative pain or acute severepain (pain not controlled with doses of oxycodone, or theequivalent of 20 mg/day or less for a patient who is under theage of 85 or over 65 kg, or more than 10 mg/day of oxycodoneif they are less than 65 kg or over the age of 85. This wouldrequire use of intravenous or subcutaneous access and wouldalso tie into the hospitals use of continuous oximetry;iv. Then it would be recommended to consider anti-elliptic drugs orTri-Cyclic antidepressants as co-analgesics after doing someform of sleep apnoea screening. No co-analgesics should beFindings of the inquest into the death of Michael James Calder Page 10prescribed with neurological effects except by the primaryphysician/Surgeon/anaesthetist;v. Finally, transitioning to sustained release oral or topicalnarcotics would only occur once stable on a steady dose of thepatient controlled analgesia. This is where fentanyl may havecertain advantages because the translation from a fentanyl PCAin terms of hourly use on average across the day to a patch ismuch easier and does not require any mathematical gymnasticswhich OxyContin and MS Contin may.55. Dr Brockett stated that on admission to the ward he was not aware that MrCalders oxygen saturation level had dropped to 79 at 19:20 hours on 8 July2014 whilst in the ED, with a respiration rate of 112. Had he been aware of theseentries this would have raised queries to try to understand why the oxygensaturations were so low. He would not have prescribed sustained releasenarcotics and would have reduced the dose level of Ordine to half, butincreasing the frequency.56. Dr Brockett stated that although the full file comes from the Emergency Centrewith a computer printout of the observations, it was not then his usual practiceto go through each and every entry. His primary reference was to the letter ofreferral from the ED with an expectation that if there had been any significantobservati