JURY URGES BETTER OVERDOSE PROCEDURES

Methadone Client Died After Being Given Wrong Dosage At Centre

A group of Ontario drug treatment centres should overhaul procedures
and policies on methadone overdoses, a coroner's jury said yesterday.

The jury panel of four women and one man found that Wade Hatt, 41,
died of a methadone overdose he received by accident at the Ontario
Addiction Treatment Centre on Somerset Street.

The jury made 16 recommendations, including "proper training" for
centre staff on clinic procedures and the development of "a clear,
succinct overdose incident response protocol."

This response protocol would include the following: "inform the
patient that he/she has taken an overdose" and "strongly encourage
the patient to go to the emergency room." In addition, the protocol
should be "made available to clinic staff, posted in each room of the
clinic and added to their policies and procedures manual."

The jury concluded that "evidence showed there was a lack of
co-ordination, organization and communication in dealing with this
methadone overdose."

In testimony, the jury heard that Mr. Hatt refused to go to hospital
after the overdose, although he was urged to by a clinic doctor. Mr.
Hatt died in his Kirkwood Avenue apartment on Oct. 15, 2005, about 12
to 15 hours after receiving the overdose at the clinic.

A nurse at the clinic mistakenly served Mr. Hatt the methadone drink
intended for his partner, Julie Maloney. Her daily dosage was 10
times more powerful than his.

The inquest shed light on the administration of methadone treatment,
as well as the shadowy world of drug addiction. The jury heard that
although Mr. Hatt's drug of choice was oxycontin, a prescription pain
reliever, he was also addicted to cocaine. Many of the 80 to 90
clients who receive daily methadone doses at the clinic are also
addicted to other drugs.

The jury also heard that there is a stigma or bias against addicts at
emergency rooms, and this bias makes many addicts reluctant to seek
hospital treatment.

Mr. Hatt and Ms. Maloney were always well-dressed and pleasant to
clinic staff. It was customary for them to be given their methadone
drinks at the same time, although this was contrary to clinic policy.

The jury made several recommendations aimed at reducing the risk of
clients receiving an incorrect dosage, including "OATC staff should
serve only one patient at the counter under all circumstances" and
"OATC nurses must witness patient reading label on bottle and have
them confirm their name and dosage is correct by initialing an acknowledgment."

The jury noted that current centre protocol provides "little
direction" on how to deal with an overdose when the client refuses to
go to hospital.

To remedy this, the jury recommended that the centre and the College
of Physicians and Surgeons of Ontario jointly develop a protocol that
would include the following:

- - Have the patient sign an "Against Medical Advice" waiver, if he
refuses to go to hospital;

- - Give the patient an information sheet "regarding signs of methadone
toxicity;"

- - Provide written advice "regarding at-home monitoring and risks involved."

As well, the jury recommended that the college and the centre should
"take initiatives to educate emergency department staff with respect
to dealing fairly with methadone overdose patients."

Linda Hatt, Mr. Hatt's mother, said she was "very satisfied" with the
recommendations, and praised the jury's hard work. She said the
five-day inquest had been "very emotional" for the family.

Karla Hatt, Mr. Hatt's sister, added that the recommendations were
"pretty much everything we wanted."

Many of the jury's recommendations directed at the treatment centre
"have been in place for quite some time," said Wayne Brynaert, the
lawyer representing doctors and staff at the Somerset Street facility.

As for the recommendations directed jointly at the treatment centre
and the College of Physicians and Surgeons of Ontario, Mr. Brynaert
said the centre "looks forward to working in a collaborative
partnership with the college to implement those recommendations as
soon as possible."