Queensland toddler died from oxycodone overdose

A Queensland coroner has warned the government to “urgently” introduce real-time prescription monitoring after a toddler died from ingesting his drug-dependent grandparents’ oxycodone.

Damien*, who lived with his mother, aunt and grandparents in Cairns, was 20 months old when he died.

Although his mother was the primary carer, it was not unusual for the child to be left, for several days at a time, in the care of his maternal grandparents, both of whom “had a known history of obtaining drugs of dependence, including oxycodone”, Coroner Nerida Wilson found on Monday.

On the morning of his death, his mother had left him home with her parents and the boy’s aunt, and “was in good spirits” despite a cold.

Damien’s grandfather had given him a bottle of chocolate milk earlier that morning and let him sleep in, after going to bed late the night before.

A few hours later, he was found cold and dead in his bed by his grandfather on 24 August, 2013.

The forensic pathologist found enough oxycodone in Damien’s blood to kill an adult.

Microscopic examination also showed some lung infection, with evidence of inhaled food and inflammation of the lining of the voice-box region.

The coroner said police were unable to determine whether Damien was given the drugs or if he took them himself.

No drugs were detected in the chocolate milk and the coroner found “there was nothing to suggest he had ever been administered oxycodone in the past to either pacify or medicate”.

Both of Damien’s grandparents had a history of “doctor shopping” for prescription pills.

Their GP, Alain Sanouiller, had prescribed a total of 560 oxycodone tablets to the couple in the month prior to the child’s death.

The grandfather conceded selling some of the oxycodone and also the possibility of Damien finding oxycodone and ingesting it.

After Damien’s death, Dr Sanouiller was investigated by the Medical Board of Australia, which imposed 10 conditions on his registration, including that he no longer prescribed oxycodone.

His registration lapsed in November 2017 and he has since left Australia; however, he does continue to have a valid prescriber number with Medicare.

In handing down her findings, Corner Wilson backed calls from a 2018 inquiry into the deaths of four other people who died after taking prescription drugs.

“Those findings articulated an issue that is confronting all coronial jurisdictions in Australia and repeated the recommendation that a real-time prescription monitoring system be implemented ‘as a matter of urgency’,” she said.

Corner Wilson said Queensland Health had told her they aimed to have the prescription-monitoring system up and running by 2020.

“I acknowledge these tangible steps taken to date towards the implementation of the real-time monitoring system, and emphasise the need for this work to continue as a matter of urgency,” she said.

*Real name not used.