DRUG CLINIC STAFF POORLY TRAINED: JURY

Not Equipped to Deal With Overdose

Inquest Finds Man's Death an Accident

OTTAWA--Ontario's largest chain of methadone clinics must improve its
dispensing practices and better train staff to handle overdoses, a
coroner's jury has found.

"There was a lack of coordination, organization and communication"
after Wade Hatt mistakenly drank more than 10 times his regular dose
of the synthetic narcotic, the inquest jury said in its ruling yesterday.

The five-person jury called for policy changes at the Ontario
Addiction Treatment Centres (OATC), which serves about one-third of
the province's 14,000 methadone patients. Nurses must witness people
taking their dose and have them initial an acknowledgement that they
are receiving the proper amount of the potentially dangerous drug.
Also, the jury said OATC should bring in strong policies on what
people should do if they ingest too much of the drug.

The jury deemed on Thursday the 41-year-old night-shift deliveryman's
death an accident. Hatt died in October 2005 after he accidentally
drank the 160-milligram dose intended for his girlfriend at OATC's
Ottawa location, one of 23 in the province. Hatt's usual dose was 15
milligrams.

Among its 16 recommendations, the jury suggested enlarging the print
size on the labels of methadone bottles and serving one patient at a
time.

During the inquest, an OATC doctor told jurors that some safeguards --
similar to those the jury recommended -- have already been put in
place. For example, patients now have to confirm by signature that
they have received their dose.

The Ottawa clinic's medical director, Andrew Everett, said during the
inquest the two nurses had no special training before they began
administering methadone. The clinic expects them to read its policy
manual within two weeks of being hired, he said, but the nurses aren't
tested to make sure they've done so.

"Evidence showed that the two nurses present during the incident
lacked knowledge of the clinic's policies," the jury found. The
clinic's procedures manual says a patient who has overdosed on
methadone should go immediately to the hospital. The jury recommended
the clinic require any patient who doesn't go to the hospital after an
overdose to sign a waiver acknowledging he or she refused medical
advice. The clinic never asked Hatt to sign such a form even though it
was its policy to do so, the inquest heard.

It was also revealed that Hatt had 32 doctor's appointments at the
clinic between July 2004 and October 2005. At these appointments,
which were separate from his regular daily methadone treatments, the
clinic tested Hatt's urine for illicit drugs. His urine tested
positive for cocaine on 18 of the 32 appointments. He told doctors
during six other appointments that he'd used cocaine.

It's not believed Hatt's cocaine use contributed to his death.
Methadone patients continue to receive treatments even if they're
taking other drugs, Everett said. However, if patients can show over
time that they're not taking any other drugs, they're able to take a
week's supply of methadone home with them. That means patients don't
have to come into the clinic each day -- an incentive to stop their
drug use, Everett said.