Friday, July 05, 2013

Coroner Slams One Suicide at Capital and Coast DHB




The New Zealand Herald are reporting that Coroner Garry Evans has slammed Capital & Coast District Health Board for its inadequate treatment of a man who killed himself after being discharged from Wellington Hospital.

This is quite a deal in New Zealand as Coroners rarely allow reporting on suicides... apparently reporting on suicides makes people want to go out and kill themselves. Yeh, right.

39-year-old Bryan John Eastwood was, as we've come to expect in these types of cases, given antidepressants to help his alcohol addiction and also to help him sleep. He'd recently separated from his wife and lost his job and was deemed to be 'anxious' by his prescribing healthcare professional.




The Herald writes:

"Two days later he went to his GP feeling "anxious and miserable" and was given anti-depressants and medication to help him with sleeping and alcohol withdrawal.
On March 13, Mr Eastwood went to Wellington Hospital's emergency department after overdosing on clonazepam and drinking up to 23 units of alcohol.
A risk assessment noted a number of concerning features including alcohol abuse, social isolation, the break-up of a significant relationship, the loss of his job and recent criminal proceedings.
Nonetheless, he was assessed as not wanting to die and, rather, the overdose was considered an attempt to get his wife's attention.
A nurse unsuccessfully tried to contact the on-duty registrar, but Coroner Evans said the telephonist may have been calling the wrong doctor.
The registrar was required to be contacted in such cases but Mr Eastwood was discharged anyway.
Nurses involved in the case commented that there was considerable pressure to discharge clients within six hours due to the hospital's "six-hour rule".

I find it odd that this poor man was deemed as just trying to get his wife's attention considering he was abusing alcohol, was in trouble with the law and was feeling socially isolated. I also find it bizarre that there's a six-hour rule in place for such cases.

Overdosing on a drug such as clonazepam could have been fatal, particularly combined with alcohol.

In the US clonazepam is better known by its brand name, Klonopin.

Former lead singer of Fleetwood Mac, Stevie Nicks, had a lot to say about the drug.  “[Klonopin] turned me into a zombie,” she told US Weekly in 2001. Nicks also described the drug as a “horrible, dangerous drug,” and said that her eventual 45-day hospital detox and rehab from the drug felt like “somebody opened up a door and pushed me into hell.” [1]

In 2009, Roche, the manufacturer of Klonopin in the US, issued a warning to prescribers of clonazepam stating that, "Roche would like to advise you of a recent change to the Klonopin Prescribing Information (WARNINGS and PRECAUTIONS sections). Based on pooled analysis of eleven antiepileptic drugs (AEDs) performed by the FDA, a class warning for increased risk of suicidality (suicidal behavior or ideation) is now required for all AEDs (including Klonopin)." [2]

Yay the coroner for allowing media reporting on this, he did so to promote public safety. Maybe though he should have dug deeper, he may have found that it was quite wrong to give such a drug to a vulnerable patient, furthermore, the drug in question, as admitted by its own manufacturers, increases the risk of suicidality.

As for Capital & Coast, they are under the radar with a recent request I made to all the DHB's in New Zealand.

I've learned from the data they sent me that between the years 2007-2010 there were 40 suicides from patients under their care, 37 of whom were on medication at the time of their suicides. 10 of those 37 were, coincidentally, taking clonazepam within the six months prior to their deaths.

If a member of the public can access information like this then I'm sure coroners can.

I'm just baffled why they don't.

Bob Fiddaman


[1] Is This the World's Deadliest Pill?
[2] Klonopin® Tablets (clonazepam) WARNING