Coroner's Court of Western Australia

Inquest into the Death of Matthew Neil Hardy TONKIN

Inquest into the Death of Matthew Neil Hardy TONKIN

Delivered on :10 May 2019

Delivered at : Perth

Finding of : Coroner King

Recommendations :Yes

Recommendation 1

That the Western Australian Department of Health liaise with the Department of Defence to consider and, if appropriate, implement a procedure to allow for the timely transfer of medical records of ADF members and veterans to treating medical professionals in Western Australia.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was from WA . He joined the Australian Defence Force and was stationed in Queensland before being deployed overseas. He injured his hip during physical training and returned to Australia in February 2013. In May 2013 he was diagnosed with PTSD.

In early June 2013 the deceased experienced increased pain to his hip and lower back pain. He was prescribed oxycodone for pain. Within a relatively short time, he became addicted to oxycodone and sedative drugs, which he began to seek and to abuse. His doctors identified the addiction and arranged for psychological therapy and reduced access to drugs, but he obtained further oxycodone through friends or by deception. He was admitted to hospital several times for overdoses.

The deceased left the Army and in early 2014 he returned to WA. GPs in WA were initially willing to prescribe him oxycodone as they were unaware of his addiction and had difficulty obtaining his ADF medical records. The prescription monitoring system for Schedule 8 drugs in WA was incapable of providing up-to-date information to prescribers.  By mid May 2014, most GPs refused to prescribe him oxycodone, partly because his drug-seeking behaviour was so apparent. On 1 July 2014, a GP prescribed him oxycodone based on his good presentation. He overdosed and died from the complication of bronchopneumonia. The coroner found that the death occurred by way of accident.

The inquest focused on the lack of a real-time prescription monitoring system for Schedule 8 drugs in WA and the difficulty medical practitioners faced had in obtaining ADF records of their patients. The Coroner identified areas of medical management where improvements might be made and recommended a procedure to allow for the timely transfer of medical records of ADF members and veterans to treating medical professionals in WA.

Catch Words : PTSD : ADF : Doctor shopping : Transfer of medical records : Schedule 8 : Oxycodone : Real-time prescription monitoring : ERCCD : Accident


Last updated: 17-May-2019

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