Coroner floats DHB changes

03:24, Jan 30 2014

The coroner has recommended changes to Nelson Marlborough District Health Board processes after a Blenheim man died when a miscommunication between his doctors meant he kept taking risky medicines.

Craig William Perham, known as Buck Egan, was found dead in his bed in Blenheim on the morning of February 2, 2012.

In her decision published yesterday, coroner Carla na Nagara said Mr Egan died from cardiac arrhythmia, secondary to methadone and amitriptyline use, with end-stage liver failure as an underlying condition.

Mr Egan was prescribed methadone for chronic pain, and was taking amitriptyline at the time he died, even though the hospital doctor looking after him had intended that medication be stopped two and a half months earlier.

"This anomaly appears to have been due to a miscommunication and/or misunderstanding between hospital doctors and Addiction Services doctors as to the management of Mr Egan's medication regime."

Methadone increases the risk of cardiac arrhythmia, and that is made worse with amitriptyline.


However, Ms na Nagara said the extent to which the amitriptyline increased the already-present risk could not be definitively established.

At the coroner's court hearing on Mr Egan's death in October, Nelson Marlborough Addiction Services clinical leader Michael Haskew told Ms na Nagara that new protocol guidelines had been developed to ensure this miscommunication between doctors did not happen again during the shift from paper-based records to electronic records.

Ms na Nagara said the district health board had taken appropriate steps to reduce the chances of a similar thing happening again.

However, she recommended the DHB also ensure the guidelines stated that hospital clinicians must contact the Addiction Service by either fax or email on the day patients are discharged to confirm the patient's medication regime.

The Marlborough Express