Warshafsky did not intend to kill himself with fentanyl, coroner concludes

Private tragedy intersects with patient safety:

At 0200h on the 19th June 2015, private tragedy intersected with patient safety. Referring to Julien, the contemporaneous medical record states, “collapse with loss of consciousness after anaesthetising the patient in theatre after about 5 minutes.” The “Cardiac Arrest / Medical Emergency Record Form” goes on to state that the “patient was blue, unresponsive with eyes rolled back.” A bag valve mask was used to ventilate and the form records a “respiratory arrest.” No drug testing was done. 1

The third point in this triangulation occurred 38 days later. Julien submitted his own hair sample for a “peace of mind” test which was positive for fentanyl and covered the period from the 7th May 2015 to the 21st of July 2015.2

The first point in this triangulation occurred roughly 30 hours previous to the respiratory arrest, his first of seven. Although known to some parties for almost two years, it was not disclosed to myself until the final days of the inquest. A further statement submitted to the coroner revealed that Julien had insisted on helping a fellow trainee anaesthetise a patient. After Julien had left, the trainee noted an ampoule of fentanyl missing. The trainee reported this to seniors. Neither incident was investigated.3
I am not aware that the inquest has closed off this dangerous intersection.

Two years before Julien came to attention, in 2011, the Anaesthetic Association of Great Britain and Ireland (AAGBI), published their excellent guidance on the problem of addiction in anaesthetists.4 When I mapped their guidance against Julien’s reality, there was no match. The guidance would not have seemed to have been followed.

One of the articles cited in the references to the guidance, is an review article on the subject.5 The authors descsribe the neurobiology of addiction: “It is known that drugs of abuse physically alter the chemistry of the addicted brain, changing the relative levels of the neurotransmitters gamma-aminobutyric acid, dopamine, and seratonin associated with reward pathways such that drug seeking behavior is favored over the rational evaluation of the risks of such actions.” They go on to state, “Physician patients are often described as having grandiose ideas of invulnerability and self-sufficiency, and are unable to accept that abuse leads to addiction and that addiction is loss of autonomy.”

The coroner stated that my son “had not acknowledged his problem and lacked the motivation to confront it and change.” This is factually untrue. The truth, as always, is much more nuanced, and therefore I am unable to describe this in detail here. Moreover, in light of current knowledge regarding addiction as Bryson et al note, in effect the coroner seems to be saying that Julien could not overcome his addiction owing to his addiction.

Our family’s solicitor and barrister asked that an expert in addiction be brought into the inquest, however the coroner, herself a part-time anaesthetist, refused our request.

Lastly, and very sadly, I have been told by Dr Michael Kaufmann (personal communication), the Medical Director of the Physician Health Programme (PHP) he founded in 1995 in Ontario, Canada, where both Julien and I were born, that had this happened there, Julien would not have died. I understand that this is arguable. However, what I would like to point out is that sick doctors in Ontario receive care and treatment confidentially. The College of Physicians and Surgeons of Ontario (CPSO) (the GMC equivalent) need not know the name of the sick doctor or anything about them except that they are being treated and are following that treatment plan. Every year I renew my registration with the CPSO (I don’t burn my bridges) and answer this question, “Do you have a substance use disorder (SUD) that is not known either to the PHP or the CPSO?” If I did have a SUD, I could legally answer no to that question if I was adhering to the PHP treatment plan.

For the time being we will not know the answer to the excellent question posed on the cover of the 16th July edition of the BMJ, “What could have been done to save Julien Warshafsky?” The inquest was a missed opportunity to correct a long trail of missed opportunities.

Dr Robin Warshafsky, MD, CCFP, MRCGP
Lead General Practitioner for Primary Care Streaming, East Sussex Healthcare NHS Trust
Clinical Advisor, NHS England, South East
robin.warshafsky@nhs.net

1. The Medway-Maritime Hospitals NHS Trust medical records 19.06.15
2. Cansford Laboratories, Certificate of Analysis 7710683 30.07.15
3. Addendum to statement from Dr Claire Mearns re Dr Julien Warshafksy – Confidential Information for Coroner’s discretion only 30.03.17
4. Dickson D et al. Drug and Alcohol Abuse amongst Anaesthetists - Guidance on Identification and Management March 2011
5. Bryson E et al. Addiction and Substance Abuse in Anesthesiology. Anesthesiology. 2008 November ; 109(5): 905–917