Facts
On 23 May 2018, the State Coroner of South Australia handed down his findings following an Inquest into the death of Ms Claudia La Bella, aged 28 years, who died on 29 June 2014 as a result of aspiration of gastric contents complicating laxative abuse. HWL Ebsworth were instructed in the Inquest.
Ms La Bella’s husband, family and friends had been told by Ms La Bella that she had been diagnosed with terminal cancer in April 2012 and that she had only 3 to 5 years to live. Following her death, it became apparent upon autopsy that there was no evidence to support her claim of terminal cancer.
The Inquest heard that Ms La Bella rarely ate and was no longer eating solid food prior to her death. Ms La Bella’s husband was aware that Ms La Bella was taking tablets which he understood was to treat her cancer. Mr La Bella regularly bought Ms La Bella boxes of Dulcolax from a Chemist King pharmacy and he understood that Ms La Bella was taking the laxative tablets because they had been injected with chemotherapy drugs by her doctors to treat the cancer.
Ms La Bella also regularly attended at the Chemist King pharmacy to purchase bulk orders of Dulcolax, the amount of which increased to 25 to 30 boxes of 200 tablets per week in the 9 or 10 months prior to her death.
Two weeks prior to her death, Ms La Bella was hospitalised at the Royal Adelaide Hospital (RAH) following stomach pain complaints. Ms La Bella was referred to the RAH by her GP who suspected an eating disorder. At the time of attendance at her GP, Ms La Bella weighed 35kg and was using a wheelchair. Although the GP informed the RAH that she suspected a eating disorder that information did not filter through to those treating Ms Bella
A CT scan undertaken at the RAH noted that there were several dozen rounded densities in Ms La Bella’s stomach compatible with tablets. Ms La Bella was an inpatient for 2 days at the RAH but discharged herself from the hospital against medical advice. The treating staff at RAH did not consider at that time that sufficient information existed to suspect an eating disorder.
Although Ms La Bella subsequently attended at her GP, her GP was not aware of the results of the CT scan and did not receive a copy of the RAH’s discharge summary until after Ms La Bella’s death on 29 June 2014.
Findings
The Coroner found that the cause of Ms La Bella’s death was aspiration of gastric contents complicating laxative abuse.
An expert psychiatrist who gave evidence at the Inquest concluded that Ms La Bella had been suffering from an eating disorder and a severe presentation of factitious disorder known as Munchausen syndrome.
The Coroner found that the evidence revealed that Ms La Bella was engaged in numerous deceptions as a result of her mental condition, particularly around her claim of terminal cancer, her medical appointments and embezzlement of money from her employer which had been occurring since 2009.
The key issues for the Coroner to consider in relation to the circumstances of Ms La Bella’s death were:
- The role of the Chemist King pharmacy in supplying bulk laxatives to Ms La Bella. The Coroner accepted the evidence of the managing pharmacist that she was not aware of the bulk sales to Ms La Bella because the laxatives were an over the counter medication which were ordered by retail staff at the pharmacy and not by a pharmacist.
The Coroner rejected the evidence of the retail manager and found that her evidence was an attempt to mislead the Court and avoid responsibility for selling large amounts of laxatives to Ms La Bella when she was well aware that Ms La Bella had an eating disorder; - The role of the RAH in treating Ms La Bella. It was noted by the Coroner that Ms La Bella actively discouraged communication about her between her doctors and family members which presented a problem in providing her treatment. Further, the doctors at the RAH were not aware that Ms La Bella had been claiming that she was suffering from terminal cancer not were they aware of the GP’s suspicion of an eating disorder.
Evidence was also given that the delays in providing a discharge summary to Ms La Bella’s GP were due to the medical service at the RAH running over capacity; and - The role of her treating GP. It was noted by the Coroner that her GP was at no stage informed of Ms La Bella’s alleged cancer diagnosis and that her GP suspected an eating disorder and attempted to have her referred to an eating disorders unit.
Recommendations
In considering the above issues, the Coroner made three recommendations directed to the South Australia Minister for Health and Wellbeing and the Australian Government Department of Health, Therapeutic Goods Administration that:
- Where there is any suspicion of an eating disorder in hospital presentations involving severe weight loss, there must be a referral to the Psychiatric Liaison Service, which is to be triggered as a matter of urgency where the patient wishes to self-discharge;
- Where a patient is discharged from hospital against medical advice, but there is an expectation that they will be treated by their GP, a personal discussion between a member of the treating team and the GP is mandatory before the patient leaves; and
- Dulcolax and like medications be classed as pharmacist only medications, requiring professional advice for safe use and should not be available for self-selection from pharmacy shelves or online stores and purchases should only be made following consultations with the pharmacist.
Although it was noted within the Findings that Ms La Bella’s circumstances were complex and rare, there are implications for risk management practices for hospitals and pharmacies arising out of the purchasing of laxatives to prevent laxative abuse, and the treatment of patients with eating disorders in particular noting that the Coroner drew his findings to the attention of the Pharmacy Board of Australia, the Pharmacy Guild of Australia, the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine.
This article was written by Michael Tilley, Partner and Jessica Carnell, Associate.