An experienced mental health nurse and psychotherapist was involved in the care of a patient over a 13-year period, where the Patient had a complex history of mental health issues and drug dependency. The practitioner provided regular one-on-one care under the NSW Mental Health Nurse Incentive Plan, in partnership with the Patient’s GP. In August 2011, the Patient died of a drug overdose as a direct result of multiple drug toxicity, including illicit drugs.

Two years prior to her death, the Patient, the practitioner and the GP engaged in an arrangement where the GP continued to prescribe the Patient Stilnox (for her chronic insomnia) and the practitioner was to act as custodian of the Stilnox and permit the Patient to access it upon request. The objective of this arrangement was to deny the Patient ready access to a highly addictive drug.

Following an inquest into the Patient’s death, the Coroner recommended that the HCCC review the practitioner’s role in the care and treatment of the Patient. Following investigation the HCCC alleged that the practitioner failed to provide adequate care and treatment. The allegations included serious recording keeping, patient consultation, communication and documentation deficiencies. It was also alleged that he supplied Stilnox in excess of what was prescribed and failed to inform the GP that the Patient had episodically abused the drug and was also doctor shopping.

Ultimately, it was determined by the Tribunal that the practitioner:  

  1. Failed on 26 occasions to keep adequate clinical records in relation to the supply of approximately 113 Stilnox tablets;
  2. Allowed the Patient access to Stilnox on over 63 occasions without personally consulting her;
  3. Failed to provide regular and timely updates to the GP, or to disclose any changes in the condition or treatment of the Patient, in particular, on two separate occasions when she consumed a box of Stilnox in a 24 hour period; and
  4. Failed to create and maintain a treatment plan.

The judgment and care exercised by the practitioner was found to fall significantly below the standard reasonably expected of a nurse with the practitioner’s level of experience and training. Further, the Tribunal found this was not a case of occasional transgression or failure to comply, but cumulative and repetitive behaviour over an extended period of time.

The practitioner was found guilty of both unsatisfactory professional conduct and professional misconduct. A decision on penalty will follow when each party has filed and served its proposed protective orders.

To read the full decision in HCCC v Cain [2017] NSWCATOD 131 click here.