Laxative sales should be restricted after death of anorexic woman, coroner says
A coroner has recommended laxative medications be taken off shelves and be made only available with pharmacist approval, following an inquest into the death of an anorexic woman who was taking hundreds of tablets each day.
Adelaide woman Claudia La Bella, 28, weighed just 35 kilograms when she died on June 29, 2014, from complications associated with laxative abuse.
An inquest before South Australian coroner Mark Johns heard the mother-of-one and her husband spent around $500 each week at the Chemist King in Hectorville buying 25 to 30 boxes of Dulcolax.
For two years, Mrs La Bella told her family and friends she had terminal ovarian cancer, to cover the symptoms of taking up to 800 laxative tablets a day.
The inquest heard Chemist King’s retail manager Jessica Cutting approved bulk orders of between 25 and 30 boxes of Dulcolax for Mrs La Bella, who either collected them in person or sent her husband.
Mr Johns found Ms Cutting was an “unimpressive witness” who lied about her knowledge of laxative abuse being associated with eating disorders.
“In my opinion she was plainly attempting to mislead the court and avoid responsibility for selling large amounts of laxatives to Claudia or her husband when she was well aware that Claudia likely had an eating disorder,” he said.
Mr Johns rejected claims by Ms Cutting that she sought approval for the bulk orders from the on-site pharmacist Carolyn Tan.
“I find that Ms Tan had no knowledge of these sales,” he said.
“Had she done so I am very confident that she would have made appropriate enquiries.”
Laxatives should become ‘pharmacist-only medications’
While on the stand, Ms Cutting who had worked at the pharmacy since 2011, said she was not aware that the recommended daily dose of Dulcolax was two to three tablets per day, for no more than a week.
“I didn’t know much about the product so I hadn’t looked [at the box],” she told the court.
She told the inquest she believed the Dulcolax was being purchased to treat and manage Mrs La Bella’s cancer.
However, under cross examination, she agreed that making regular profits from the bulk orders meant she was doing her job “effectively” and that she did not feel any ethical dilemma in authorising such large orders of laxatives.
Mr Johns recommended Dulcolax and other laxatives be classed as “pharmacist-only medications,” the safe use of which requires professional advice.
“They should not be available for self-selection from pharmacy shelves or online stores and purchases should only be made following consultation with the pharmacist,” he said.
“I draw this finding to the attention of the Pharmacy Board of Australia, the Pharmacy Guild of Australia, the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine.”
Victim suffered from Munchausen syndrome
The inquest also heard Mrs La Bella was allowed to self-discharge from the Royal Adelaide Hospital nine days before her death despite being dangerously underweight and a scan showing dozens of pills in her stomach.
Dr Paul Drysdale said he decided against detaining her under the power of an inpatient treatment order because he did not have a “clear-cut diagnosis of a mental illness”.
He told the inquest he was not certain the objects identified in the scan of Mrs La Bella’s stomach were pills, despite the radiographer’s report suggesting they were, and believed they could have been seeds.
Mr Johns recommended that when patients with severe weight loss present to hospital there must be an urgent referral to the Psychiatric Liaison Service if there is any suspicion of an eating disorder.
He also recommended that when a patient is discharged from hospital against medical advice — but with an expectation they will be treated by a general practitioner — that a member of the treating team speak with the GP before the patient leaves.
Consultant psychiatrist Dr Maria Naso assessed the case and found Mrs La Bella had anorexia nervosa and a factitious disorder in its severest form known as Munchausen syndrome or Munchausen by proxy.
Mr Johns accepted that Mrs La Bella went to extraordinary lengths to be secretive about her health and about any appointments she was claiming to attend.
“Not only was this a problem for family members, but as will be seen, it was clearly a problem for those in the health system who were attempting to assist Claudia,” he said.
The inquest heard Mrs La Bella’s husband believed his wife’s claims that her doctor had injected the chemotherapy drugs into the laxative tablets as a way of receiving treatment and flushing toxins out of the body.