But it was acute liver failure from pharmacy-facilitated paracetamol overuse that had led to his painful death, the coroner found.
McHugh was put on the maximum daily dose of paracetamol – four grams per day – when he was discharged as a psychiatric inpatient from Frankston Hospital in Melbourne’s south-east in July 2022.
The Coroners Court of Victoria investigated Paul McHugh’s death.Credit: Joe Armao
The prescription allowed only for about 12 days of the drug at that dosage, but his pharmacy continued to give him the dose for 16 weeks, contrary to instructions, until mid-November 2022, the coroner found.
McHugh – who took the drugs from “webster packs”, or blister packs in which the pharmacy organised his medication – began reporting symptoms consistent with paracetamol overdose to a mental health case manager in August 2022. He died on December 8 the same year.
“On [November 24, 2022], [McHugh’s mother] Rosalba recalls that ‘Paul was very sick’ – he had become immobile, was hallucinating and in extreme pain. At this time, Paul had been taking four grams of paracetamol a day for approximately 16 weeks,” Giles said in her findings in the Coroners Court of Victoria.
“There is no evidence that pharmacists dispensing Paul’s medication turned their minds to the potential adverse effects of continuing to dispense paracetamol, even after having provided him with the maximum daily dose paracetamol for approximately 16 weeks.”
The pharmacy spoke to McHugh’s doctor at least five times between July and November 2022 about the contents of the blister packs, but – according to documented notes from the conversations – the paracetamol never came up, the coroner said.
The pharmacy failed to explain why they continued to give McHugh the high dose, only saying they “formed a belief” Frankston Hospital intended for McHugh to have regular paracetamol after he was discharged. There were no repeat prescriptions to suggest as much.
Loading
“I am troubled that the pharmacists ‘formed a belief’ as to Paul’s clinical care rather than consulting with the original prescribing clinicians or Paul’s GP,” Giles said.
Letting pharmacists prepare clients’ webster packs without consulting their treating doctors was “fraught” – particularly in McHugh’s case, when the need for diligence was “paramount”, the coroner said.
She recommended the Pharmacy Guild of Australia inform pharmacists about McHugh’s case, and encourage them to review how non-prescribed medications are dispensed in webster packs.
The Pharmacy Guild of Australia said it would consider the recommendations in the coroner’s report before formally responding.
“The guild will carefully consider the coroner’s recommendations following this inquest,” a spokesperson said.
Our Breaking News Alert will notify you of significant breaking news when it happens. Get it here.
