Tristen and Gabriel

‘One of the single biggest issues for people with disability is the overprescribing and dangerous prescribing of medications that causes significant harm and death.’

In the late 2010s, Tristen, then in his late teens, injured himself at work. His GP prescribed opioids to treat his pain.

Tristen’s dad, Gabriel, told the Royal Commission that Tristen’s injury prevented him playing sport and his mental health deteriorated. He struggled with depression and anxiety and, unable to exercise, became obese and developed sleep apnoea. His GP gave him sedatives and an antidepressant.

Gabriel said Tristen’s GP failed to ‘monitor the amount of prescriptions or the quantity of medications’ and Tristen became addicted to the opioids and sedatives. ‘His GP never explained the extremely dangerous risks of respiratory depression, coma and death, especially with someone with sleep apnoea.’

Tristen began experiencing suicidal ideation and twice was admitted to hospital after overdosing on his medication. Although he was ‘in crisis’ the public hospital wouldn’t admit him to the psychiatric unit. The treating psychiatrist said the unit was filled with ‘violent, dangerous patients … and he would likely come out of the facility more distressed’. He suggested a private psychiatric hospital would be more appropriate.

After a five-month wait, Tristen was admitted to a private clinic. He stopped taking opioids and started taking a different antidepressant. Gabriel said Tristen’s mental health appeared to improve.

When Tristen left hospital eight weeks later, he was taking six different drugs. They included an antipsychotic, two antidepressants, an antihypertensive, an anticonvulsant and a sedative.

A few days later Tristen bought an over-the-counter antihistamine.

A week after that, Tristen aggravated his injury playing sport. His GP prescribed two opioids, even though he’d promised Gabriel he wouldn’t give Tristen opioids ever again.

Two days later Tristen experienced a panic attack and the GP prescribed a sedative. That afternoon, Tristen seemed confused and drowsy and had difficulty walking. Gabriel immediately called an ambulance to take Tristian to the emergency department of a private hospital.

Despite the emergency doctor noting ‘a red flag for addictive substances’ the doctor gave Tristen another opioid script.

The next night Tristen stayed with Gabriel because he was concerned about how much medication he was on. He asked Gabriel to book him into the private psychiatric clinic again so the psychiatrist could review his medication.

Gabriel was worried about Tristen and checked on him multiple times during the night. When he checked on him the next morning Gabriel found him snoring loudly. However when he checked again a short time later, Tristen was unconscious. Gabriel immediately started trying to resuscitate his son and called an ambulance.

Tristen couldn’t be revived. He was in his early 20s.

The autopsy concluded Tristen ‘died due to the toxic reaction of his prescribed medications, taken as directed, exacerbated by his existing health conditions’.

Gabriel believes the mixture of medications prescribed by multiple practitioners caused his death. He particularly blames Tristen’s GP for continuing to prescribe opioids, despite knowing he was addicted, and for not monitoring him appropriately. Gabriel said the GP never referred Tristen to a pain management specialist or investigated alternative treatments.

Gabriel says consumers are not given adequate information about the risks of taking certain medication, particularly opioids and sedatives.

‘I blamed myself for what happened to [Tristen], I felt that I’d failed him. After doing my research and finding out the medications he was on and how they all interacted with each other and interacted with his sleep apnoea … I soon realised that there was no blame on my shoulders, I’d done everything humanly possible to help him and to protect him and to ultimately try and save him.’