Paul was in agony from paracetamol overuse. Health professionals ‘didn’t listen’, then he died

In October 2022, Paul McHugh scrawled a note on a piece of paper. “Something is happening to me and I don’t know is very very bad [sic],” it read.

Two months later, he died on his 47th birthday.

A coroner found Paul McHugh’s death could have been prevented after his pharmacy gave him an ultimately fatal dose of paracetamol for months on end.Credit: Getty Images/Cultura RF

A coroner this month found McHugh’s death could have been prevented, after his pharmacy gave him an ultimately fatal maximum daily dose of paracetamol for months on end.

He complained in the 12 months before his death, “why don’t the doctors believe me when I tell them I am in excruciating pain”, his mother told a coroner.

Around the time he scrawled the note, McHugh described his symptoms to a doctor, and paracetamol-induced liver failure was likely to blame for some of them. But they were misconstrued as being caused by other conditions.

“These symptoms included difficulty breathing, anxiety, ‘bad thoughts’, incoordination and dizziness, constipation, abdominal pain, difficulty urinating, inappetence, fatigue and difficulty swallowing,” Coroner Ingrid Giles said in a decision published last week.

“By this time, Paul would have been consuming the high-dose paracetamol for 10 to 14 weeks beyond his discharge from [Frankston] Hospital.”

Throughout his life, McHugh had lived with intense trauma from childhood abuse, substance abuse, multiple “extremely significant illnesses”, “untreatable pain”, an acquired brain injury from a car crash in 2011, suicidal ideation and several psychiatric diagnoses, the coroner said.

But it was acute liver failure from pharmacy-facilitated paracetamol overuse that had led to his painful death, the coroner found.

McHugh was put on the maximum daily dose of paracetamol – four grams per day – when he was discharged as a psychiatric inpatient from Frankston Hospital in Melbourne’s south-east in July 2022.

The Coroners Court of Victoria investigated Paul McHugh’s death.Credit: Joe Armao

The prescription allowed only for about 12 days of the drug at that dosage, but his pharmacy continued to give him the dose for 16 weeks, contrary to instructions, until mid-November 2022, the coroner found.

McHugh – who took the drugs from “webster packs”, or blister packs in which the pharmacy organised his medication – began reporting symptoms consistent with paracetamol overdose to a mental health case manager in August 2022. He died on December 8 the same year.

“On [November 24, 2022], [McHugh’s mother] Rosalba recalls that ‘Paul was very sick’ – he had become immobile, was hallucinating and in extreme pain. At this time, Paul had been taking four grams of paracetamol a day for approximately 16 weeks,” Giles said in her findings in the Coroners Court of Victoria.

“There is no evidence that pharmacists dispensing Paul’s medication turned their minds to the potential adverse effects of continuing to dispense paracetamol, even after having provided him with the maximum daily dose paracetamol for approximately 16 weeks.”

The pharmacy spoke to McHugh’s doctor at least five times between July and November 2022 about the contents of the blister packs, but – according to documented notes from the conversations – the paracetamol never came up, the coroner said.

The pharmacy failed to explain why they continued to give McHugh the high dose, only saying they “formed a belief” Frankston Hospital intended for McHugh to have regular paracetamol after he was discharged. There were no repeat prescriptions to suggest as much.

“I am troubled that the pharmacists ‘formed a belief’ as to Paul’s clinical care rather than consulting with the original prescribing clinicians or Paul’s GP,” Giles said.

Letting pharmacists prepare clients’ webster packs without consulting their treating doctors was “fraught” – particularly in McHugh’s case, when the need for diligence was “paramount”, the coroner said.

She recommended the Pharmacy Guild of Australia inform pharmacists about McHugh’s case, and encourage them to review how non-prescribed medications are dispensed in webster packs.

The Pharmacy Guild of Australia said it would consider the recommendations in the coroner’s report before formally responding.

“The guild will carefully consider the coroner’s recommendations following this inquest,” a spokesperson said.

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