A Sydney psychotherapist has been referred to the medical complaints body over his care of a woman who died with a cocktail of drugs in her system.
David Cain, also a mental health nurse, spent almost 13 years treating Rebecca Kendrew before her death between August 17 and 18, 2011.
Deputy State Coroner Sharon Freund found Ms Kendrew died as a result of multi-drug toxicity at her Homebush unit in Sydney's west, but ruled it "accidental".
Kendrew, 35, had a long and complex history of both mood and anxiety disorders, Ms Freund said, coupled with sleep disturbance prior to her death.
For a number of years she used and abused Stilnox - at times, taking up to a packet of 14 tablets per day without significant sedation.
To help control her use, she informally entered an "unorthodox" arrangement in around 2006 with Mr Cain, who agreed to safe-keep her sleeping and anxiety medications so he could "closely regulate and distribute the amount of medication Rebecca had access to".
But during cross-examination, Mr Cain conceded that - on at least one occasion - he gave Ms Kendrew four Stilnox tablets when he was only supposed to provide one.
He also admitted he knew she was getting prescriptions for the medication from other doctors but did not report it her GP.
He was often not paid for delivering the medication and only had incomplete notes of his sessions with her that did not specify any agreement or treatment plan.
"The care and treatment provided by Mr Cain ... whilst well intentioned, left Rebecca exposed to her own vulnerabilities and demons and was left wanting in a number of respects," Ms Freund said.
She recommended the Health Care Complaints Commission review the role Mr Cain had in the care and treatment he provided Ms Kendrew between 2008 and 2011.
© AAP 2024
