Bowen and Military Rehabilitation and Compensation Commission
[2006] AATA 291
•30 March 2006
Administrative
Appeals
Tribunal
DECISION AND REASONS FOR DECISION [2006] AATA 291ADMINISTRATIVE APPEALS TRIBUNAL Nº V2003/1121
GENERAL ADMINISTRATIVE DIVISION
Re: MARY MARGARET BOWEN
Applicant
And:MILITARY REHABILITATION AND COMPENSATION COMMISSION
Respondent
DECISION
Tribunal: Regina Perton, Member
Date:30 March 2006
Place:Melbourne
Decision:The Tribunal affirms the decision under review.
(sgd) Regina Perton
Member
COMPENSATION – cause of death – unintended consequence of medical treatment – whether condition caused or aggravated by medical treatment paid for by the Commonwealth - elective surgery for oesophagitis – post operative haemorrhage - medication prescribed for psychiatric condition while in Army service – whether oesophagitis caused or aggravated by medication – decision affirmed
Safety, Rehabilitation and Compensation Act 1988 s 6A
REASONS FOR DECISION
30 March 2006 Regina Perton, Member
1. Mary Bowen is the widow of the late Dr John Bowen, who died on 23 June 2000, aged 44 years. Dr Bowen died of a haemorrhage following gastric surgery. Dr Bowen, a medical practitioner, served in the Australian Army (the Army) for over 20 years. He completed his Army service on 6 February 2000.
2. On 20 September 2002, Mrs Bowen lodged a claim for compensation in relation to the death of Dr Bowen. Mrs Bowen claims that Dr Bowen would not have undergone surgery and subsequently died had it not been for the anti-depressant medication prescribed for his psychiatric condition which had been paid for by the Army. The medication required to treat the psychiatric condition is claimed to have caused and/or aggravated the gastric condition. The respondent denied that the psychiatric condition was work-related or that the medication had caused the gastric condition and refused the claim in relation to the death. The Tribunal, in a decision handed down simultaneously (V2003/1121), has determined that Dr Bowen’s psychiatric condition was work-related.
3. In this matter, the Tribunal needs to consider whether the medication taken for Dr Bowen’s psychiatric condition resulted in, and/or aggravated his gastric condition which led in turn to the operation and ultimately to his death following post-surgical complications.
RELEVANT LEGISLATION
4. Section 6A of the Safety, Rehabilitation and Compensation Act 1988 (the Act), applies in this case:
6A(1) ...
(2) If, at any time, whether before, on, or after, 1 December 1988:
(a)an employee to whom this section applies received or receives medical treatment paid for by the Commonwealth; and
(b)as an unintended consequence of that treatment the person suffered or suffers an injury;
the injury to the employee is taken to have arisen out of, or in the course of, the person’s employment, whether or not the person has remained an employee to whom this section applies. *
5.Injury and medical treatment are defined in s 4(1) of the Act:
injury means:
(a)a disease suffered by an employee; or
(b)an injury (other than a disease) suffered by an employee, being a physical or mental injury arising out of, or in the course of, the employee’s employment; or
(c)an aggravation of a physical or mental injury (other than a disease) suffered by an employee (whether or not that injury arose out of, or in the course of, the employee’s employment), being an aggravation that arose out of, or in the course of, that employment;
…
medical treatment means:
(a)medical or surgical treatment by, or under the supervision of, a legally qualified medical practitioner; or
…
EVIDENCE
Coroner’s report
6. Heather Spooner, Coroner, in a Record of Investigation into Death, dated 10 March 2004, found that Dr Bowen’s death on 23 June 2000 was from:
1(a). HAEMORRHAGE (ASSOCIATED WITH SURGERY)
in the following circumstances:
At about 7.25 p.m. on Friday 23rd June 2000 Dr John Bowen aged 44 years suffered a cardiac arrest at Baronor Private Hospital. He had been admitted to the Hospital for an elective Laproscopic Nissen Fundoplication earlier that day and arrived in theatre at 9.35 a.m. Although the procedure was uneventful, Dr Bowen suffered severe post operative bleeding and his condition deteriorated. Efforts to resuscitate Dr Bowen were ceased at 8.38 p.m.
Joint Health Support Agency
7. In a Minute dated 23 July 2003 (T23), Dr B G Rohan provided information on the anti-depressant medication provided to Dr Bowen while he was still in the Army:
a.19 Feb 96 and probably 22 Feb 96, Aurorix 150mg (three daily) for depression;
b.26 Feb 96 and probably 3 Mar 96, Aurorix 150mg (four daily);
c.Aurorix was ceased in late June 1996;
d.16 July 97, Zoloft 50mg daily for long standing dysthymia with intermittent episodes of major depression;
e.8 Aug 97 probably, Zoloft 200mg daily;
f.2 Aug 99, medication changed to Prozac 20 mg daily for anxiety/depression;
g.late August/early September 1999, Prozac ceased;
h.about 4 Sep 99, Serzone commenced for anxiety/depression.
…
3. Dr Bowen experienced severe reflux type gastrointestinal symptoms in August 1999, when his anti-depressant medication was changed to Prozac (subsequently ceased).
4. On 4 Oct 99, Dr G Wright preformed a gastroscopy on Dr Bowen which revealed a hiatus hernia, oesophagitis and areas of Barrett’s mucous.
…
Dr Bowen’s evidence
8. In an extract from a claim form in which he sought to have his gastric condition accepted as a defence-related injury (T28 p212), Dr Bowen stated that he was suffering from Barrett’s Oesophagus. He stated that he first became aware of the disability on 4 October 1999. In response to the question asking why he believed that his service caused, contributed to or aggravated this disability, Dr Bowen stated:
My accepted condition of depression was treated for years with “Zoloft”. Then “Prozac” caused pain. This led to an oesophagoscopy which made the diagnosis. The diagnosis was confirmed on biopsy. “Zoloft” and “Prozac” cause peptic injury.
Mrs Bowen
9. Mrs Bowen stated that Dr Bowen began experiencing symptoms of oesophagitis in late 1998 and that the effect was quite pronounced by early 1999. She observed that when Dr Bowen took his antidepressants the pain would sometimes be so bad that he would fall to the ground. She later clarified that there had only been one such occasion that she had observed. She stated that he felt better after eating something creamy such as full-cream milk or yoghurt and did so often to try and settle his stomach.
10. Mrs Bowen stated that she observed different symptoms in Dr Bowen when he changed from Zoloft to Prozac in about July 1999. She indicated that Prozac appeared to be less effective in dealing with the depressive symptoms than Zoloft had been and that the gastric condition seemed to worsen. Mrs Bowen stated that he had been taking Losec to deal with gastric reflux. She said that increasing the dosage of Losec did not help; and even on the maximum dose of Losec, he was eventually not able to take his antidepressants, resulting in his depression becoming considerably worse. She stated that Dr Bowen was unable to take the antidepressants from late 1999 until his death in June 2000 because of reflux pain.
11. Mrs Bowen said that her husband had decided to have the operation because he believed it was his only hope of being able to resume antidepressant medication. She stated that he had explored all the other options and had discussed the matter with several friends and former colleagues before deciding to have the surgery.
12. Mrs Bowen stated that she did not know if Dr Bowen was taking antidepressants when they met in 1991. She said that she first became aware he was taking antidepressant medication in 1996. Mrs Bowen stated that when Dr Bowen started to take Zoloft, he experienced gastric problems including loose bowel movements, rumbling tummy, he was eating more, those sorts of things. She stated that as a non‑medical person, she was unable to ascribe these symptoms to the Zoloft but that Dr Bowen’s reflux really kicked in at the end of 1999. She recalled that he reacted particularly badly to the Prozac which he took from early August to early September 1999. Mrs Bowen said that her husband was not on any medication for two to three months before the surgery. Mrs Bowen said that Dr Bowen had told her that his doctor had told him that the antidepressants had sparked the reflux.
Dr Wright
13. In a letter dated 7 June 2000, addressed to Dr C Tenni, who had referred Dr Bowen to him(T17), Dr Gavin M Wright, Thoracic and Upper Gastro Intestinal Surgeon, stated:
…Thanks for referring John, whom I met when we were in the Defence Force. I also scoped him for severe oesophagitis secondary to both his antidepressant and uncontrolled reflux. At that time I found islands of non-dysplastic Barrett’s oesophagus amoungst [sic] the oesophagitis.
Since then he has been poorly controlled on twice-daily Losec and a prokinetic (which, as you mentioned is giving him diarrhoea), having both breakthrough and immediate rebound symptoms.
Not only is John a candidate for definitive anti-reflux surgery, he actually has run out of all other options.
I have discussed the pros and cons of laparoscopic fundoplication with him, in particular the temporary dysmobility post-operatively which will reduce his oesophageal clearance. This is of significance in that he will not be able to recommence his anti-depressants until at least a month has passed…
14. In a report dated 16 July 2001 (T18), Dr Wright stated:
Dr. Bowen was referred to me for management of his reflux oesophagitis. He had been well controlled on antacid medication until he commenced his anti-depressant drug which caused him uncontrolled reflux symptoms and endoscopically he had increased oesophagitis with new ulceration. In addition he had a short segment of Barrett’s oesophagus and a small hiatus hernia.
My recommendation to Dr. Bowen to have anti-reflux surgery was based on his intolerance to the anti-depressant and his desire to be on this medication without exacerbation of his reflux symptoms. Unfortunately Dr. Bowen died of post operative haemorrhage after having the anti-reflux surgery despite intensive resuscitation and salvage laparotomy.
It is quite clear that via the decision making process his death was directly related to his depression and the complications of treating that depression and therefore any compensation related to the depressive illness should also apply to subsequent events.
15. Dr Wright was not called to give oral evidence. The Tribunal was informed that this was due to legal action Mrs Bowen had initiated against him.
Dr Cronin
16. In a report dated 3 March 2005 (Exhibit A1), Dr John Cronin, who was Dr Bowen’s psychiatrist from July 1996 until his death, stated the following in response to a question from Mrs Bowen’s solicitors about the contribution of the anti-depressant medication to Dr Bowen’s oesophagitis:
Dr Bowen reported abdominal discomfort, which he referred to as gastritis on several of the anti-depressant medications that were prescribed for him, including Efexor, Zoloft and Serzone. These anti-depressants each have dyspepsia and gastritis as adverse effects and Serzone additionally has esophagitis as an adverse effect. In my practice patients on anti-depressant medication commonly complain of dyspepsia and abdominal pain and if they are suffering pre-existing gastrointestinal disease, these symptoms are frequently exacerbated. These symptoms frequently respond to the use of anti-ulcer medication. I have not previously seen a patient need to go onto surgical treatment for severe esophagitis and uncontrolled reflux as a result of taking anti-depressant medication. As I am not a gastroenterologist or pharmacologist I am unable to state whether Mr Bowen’s prescribed medication materially contributed to or caused severe esophagitis and uncontrolled reflux.
17. In oral evidence, Dr Cronin stated that he first prescribed Zoloft to Dr Bowen in July 1996. Dr Bowen had previously been prescribed Aurorix which he had stopped using shortly before his first visit to Dr Cronin. Dr Cronin stated that the initial dosage of Zoloft was 55mg daily. Dr Cronin indicated that the dosage increased to 100mg daily around February 1997 and to 200mg daily later in that year. Dr Cronin said that the dosage was increased as Dr Bowen had an inadequate response to the medication. Dr Cronin stated that he changed the medication from Zoloft to Prozac because of the lack of effect of Zoloft.
18. Dr Cronin recalled that Dr Bowen had mentioned he had pains in his stomach. He stated that Dr Bowen had not used the term oesophagitis but rather gastritis and pain in the stomach. Dr Cronin said that it is not easy for a patient to distinguish between pain in the oesophagus or in the stomach. Dr Cronin stated that the use of milk or yoghurt as an aid in calming the symptoms tended to be typical of gastritis. Dr Cronin stated that, in his experience, it is common that patients experience pain in the stomach as a result of taking antidepressants. He stated that Dr Bowen complained of pain when he was changed to Prozac and continued to do so when changed to Serzone. Dr Cronin indicated that on one occasion, Dr Bowen presented to my rooms in a great deal of distress and required milk drinks and antacids before he could talk to me. Dr Cronin stated that Dr Bowen had not complained of pain when he first consulted him but that the gastric symptoms got worse as time went on and they tried different antidepressants in an attempt to find something that would not cause the adverse side effects.
19. Dr Cronin stated that Dr Bowen stopped taking antidepressants in October 1999. Dr Cronin said that Dr Bowen had told him that this was because of a combination of pain and relative ineffectiveness of the medication. Dr Cronin said that it was possible that the symptoms were independent of the antidepressants and that Dr Bowen was developing a stomach problem anyway. He said that he had not previously seen oesophagitis caused by antidepressant medication but that it was not his area of expertise.
20. Dr Cronin said that his comments concerning the adverse effects of Zoloft and Serzone in his report of 3 March 2005 were based on the on-line version of the MIMS Compendium (MIMS). He said that Serzone was no longer in the MIMS because it is no longer on the market.
Dr Walton
21. Dr Lester A Walton provided a psychiatric report dated 28 April 2005 (Exhibit R3). Dr Walton’s comments on the connection between the medication and the oesophagitis are:
5. Specifically in relation to the connection between the antidepressant medication and the onset of reflux symptoms/Barrett’s oesophagitis, that is a question worded with a degree of specificity placing it outside my area of expertise. As indication in the body of the report, it is not at all uncommon for patients being treated with antidepressant medications to complain of gastric distress. Very commonly such symptoms would fall well short of diagnosable reflux oesophagitis and, in my experience, the gastrointestinal symptoms are usually relatively easily managed by switching to an alternative antidepressant or adding in an antiulcer agent. In my clinical career to date, I have not encountered a patient who has gone on to surgical intervention on the specific basis of antidepressant-induced gastrointestinal symptoms.
Dr Reid
22. Dr Donald Reid, a consultant physician practising as a gastroenterologist, provided a report to the respondent dated 25 August 2003 (T25). In response to a question asking his opinion as to whether Mr Bowen suffered an injury as a result to antidepressant medication provided by the Commonwealth, Dr Reid stated:
In my opinion, Mr Bowen did not suffer an injury as a result of antidepressant medication provided by the Commonwealth. I have never met oesophagitis caused by antidepressant medication. The MIMS Pharmaceutical Database, August 2003, lists that Prozac may cause diarrhoea, nausea, dyspepsia and vomiting. It states that this may be enough in 3.0% of users to cause discontinuance of the drug. The above symptoms could be caused by Prozac, but I would have expected them to be temporary and to cease once the Prozac was stopped. In addition, I would not consider the mechanism of the above symptoms was gastro-oesophageal reflux disorder causing oesophagitis. The mechanism of the symptoms would have been a non-specific irritation of the whole gastrointestinal tract of a temporary kind only.
The Australian Medicines Handbook does not mention oesophagitis or severe dyspepsia for either the selective serotonin reuptake inhibitors (SSRIs i.e. Zoloft and Prozac) or for Aurorix or Serzone.
The two-volume textbook of Gastrointestinal and Liver Disease by Sleisinger and Fortran, 7th Edition, 2002 (The bible of gastroenterology) does not describe any adverse effects on the oesophagus from antidepressants.
There is a disorder called by the Americans “pill oesophagitis”. Sleasenger and Fortran list approximately 20 tablets capable of causing this; antidepressants are not mentioned. If a “pill” does irritate the oesophagus to cause “pill oesophagitis” it is a once only local injury to the oesophagus by the “pill”, which one would expect to recover quickly within a few days and the whole condition is a different condition to chronic gastro-oesophageal reflux disorder – oesophagitis. In their chapter on “Pathogenesis” (the mechanism and origin) of gastro-oesophageal reflux disease – oesophagitis, Sleisenger and Fortran did not mention antidepressant medications at all.
23. To a question asking whether any other factors were responsible, in part or in full for Mr Bowen’s oesophagitis, Dr Reid’s response was:
Gastroesophageal Reflux Disease and Barrett’s oesophagus develop because there is a defect of the sphincter mechanism at the junction of the oesophagus and stomach and this allows hydrochloric acid secreted by the stomach to reflux back into the oesophagus and burn it and damage it. This problem is extremely common in the Australian population. Why the sphincter mechanism fails at the junction of the oesophagus and stomach is not well understood. Having the hiatus hernia may have predisposed to the sphincter failing. The reason why certain individuals have hiatal hernias is also not well understood and cannot be attributed to any occupation or work.
I do not consider chloroquine or antidepressant medications would have contributed to his oesophagitis.
Other factors were responsible for Dr Bowen’s oesophagitis, but as is the case with most individuals with this disorder, I am unable to give a direct specific other factor as a cause.
24. In his oral evidence, Dr Reid stated that none of the antidepressant drugs taken by Dr Bowen, namely Aurorix, Zoloft, Prozac and Serzone, would have caused oesophagitis. He also stated that it was his opinion that on the balance of probabilities, the drugs would not have aggravated or accelerated any underlying problems in Dr Bowen’s stomach or oesophagus.
25. Dr Reid was referred to extracts from MIMS concerning Zoloft and Prozac and to manufacturer’s documents concerning those drugs, which had been approved by the United States Food and Drug Administration. The manufacturer’s Prozac document listed a number of observations during clinical trials including frequent problems of increased appetite, nausea and vomiting. Under infrequent, the document referred to oesophagitis. Dr Reid stated that he would like to know how the manufacturer defined infrequent. He said that MIMS attempts to define what they mean by the word uncommon, and refers to frequencies of one in a hundred or one in a thousand etc.
26. Dr Reid stated that the most respected book on the adverse effects of drugs in Australia is the Australian Medicines Handbook (the Handbook) produced by the Pharmacological Society of Australia and the Pharmaceutical Society of Australia. He indicated that the Handbook does not mention oesophagitis as a possible effect of the antidepressants prescribed for Dr Bowen. He stated that none of the text books on gastroenterology mention antidepressants in their discussion of oesophagitis.
27. Dr Reid stated that there are two main kinds of oesophagitis. The common kind in 99% of cases is reflux oesophagitis. He stated that a rare kind is pill oesophagitis or medication oesophagitis where during the swallowing of the tablet it may lodge and get stuck in the oesophagus and then burn the lining in a focal area. Dr Reid said that many tablets can cause pill oesophagitis but he is not aware of Prozac being one of them. He later added that there can be other causes of oesophagitis apart from reflux which result from a virus or the swallowing of caustic soda.
28. Dr Reid was referred to an entry in the Zoloft manufacturer’s documents which stated that oesophagitis was an infrequent adverse effect of the drug. Dr Reid stated that he has worked in the field for 35 years and has never encountered such a complication from Zoloft. He reiterated that there was no mention of such a side effect of Zoloft in the Handbook or the textbooks. He stated that the Handbook is more authoritative than the manufacturer’s information.
29. In cross-examination, Dr Reid stated that MIMS is wrong in stating that Prozac causes reflux oesophagitis. He indicated that MIMS Annual will list everything that anyone might ever have said was a side effect of a drug. The MIMS Monthly, which he used in his report, has an abbreviated list. Dr Reid stated that there is a saying amongst medical doctors that if you look at the full MIMS every drug has every complication and you are left baffled and I think when I am reading about Prozac and Zoloft is a bit like that. In relation to Serzone, Dr Reid stated that he has no specific knowledge of its impact before it was withdrawn. He stated that he doubted that it would cause gastro-oesophageal reflux disease or oesophagitis
30. In re-examination, Dr Reid stated that he has been practising in the field for 35 years, including two years research work in the United States poking tubes down the oesophagus 12 hours a day. He stated that his hospital, the Royal Adelaide Hospital, is one of the world centres for oesophageal work. He said that he had discussed the case with colleagues, including two who are world authorities in the field and they had all agreed that whey would not support the contention that antidepressants significantly affect gastro-oesophageal reflux and oesophagitis.
31. Dr Reid stressed that if he was at a scientific medical meeting, MIMS would never be mentioned. The sources of data they would use include original papers, textbooks, reputable journals etc. He said that all the material in MIMS has been produced by the pharmaceutical company and it is in the company’s interest to mention every complication ever reported even though it may or may not be causal. Dr Reid stated that if he was treating someone with oesophagitis, he would not stop their use of antidepressants.
Dr Stevenson
32. Dr Peter Stevenson, consultant physician, provided a report dated 10 August 2005 (Exhibit R1). He indicated that he has seen numerous patients with conditions similar to that of Dr Bowen. Dr Stevenson stated that he had difficulty following the logic in the arguments put by Dr Wright in relation to Dr Bowen’s death being directly related to the treatment of depression. Dr Stevenson stated, in response to a question as to his awareness of any connection between the medication and his gastric condition:
No, I have looked critically at the issue, and I am not. My understanding is that Dr Bowen was treated for his psychiatric condition presumably with the recent SSRI class of antidepressant medication. Dr Reid’s review, I am sure, is perfectly correct. I have read numerous articles and textbooks on both treatment of depression and on gastroesophageal reflux disorder. I am aware of no such association and one seems plausible. I reviewed few recent review articles and no such association was noted.
I then performed a computer Medline search on possible associations of antidepressant medication and gastroesophageal reflux disorder. I found only one possible relevant reference – a Case Report by Tyber in the American Journal of Psychiatry, June 1975, on the relationship between hiatus hernia and tricyclic antidepressant medication, five cases. Two cases were said to have experienced aggravations of pre-existing hiatus hernia. It was suggested that the anti-cholinergic effect of the tricyclic medication might have an effect on the oesophageal sphincter.
I found no larger study replicating this association in the ensuing 30 years. If the agent taken by Dr Bowen was Prozac, this is of course an SSRI antidepressant with totally different pharmacological action. The proposed association therefore is irrelevant. …
Dr Reid’s review is erudite and correct. Most medications, particularly if taken in excess, may cause transient inflammation of the stomach, resolving after cessation…
…
My conclusion must therefore be that the medication for his psychological condition was irrelevant to his gastroesophageal reflux. Gastroesophageal reflux disorder is very common in the general population. The incidence increases with the aging process. The reasons for progressive incompetence of the gastroesophageal sphincter are widely researched and debated and appear to reflect constitutional abnormality to muscle tone. I am aware of no studies that have shown any substantive association with psychiatric illness or any relevant medication.
33. In his oral evidence, Dr Stevenson indicated that he did not disagree with the comments made by Dr Reid in his report. He stated that all the SSRI class of antidepressants can have gastro-intestinal side effects but that the figures are low. He stated that the SSRI antidepressants are not highly toxic to the stomach as compared with other classes of drugs. Dr Stevenson said that any medication, if taken in excess or without water or food, can cause transient inflammation of the oesophagus and stomach. He stated that taking Aurorix or Zoloft, even if the person had a transient side effect, would not have had any aggravating or accelerating effect on any pre-existing gastric condition. Dr Stevenson said the transient irritation would not have lasting effects on the function of the gastro-oesophageal sphincter. He commented that Dr Bowen appeared to have tolerated Aurorix and Zoloft for some three years so that the side effects would seem to have been absent or minor.
34. In relation to Prozac, Dr Stevenson stated that nausea can be a side effect of taking Prozac. He said reflux may well have been occurring for gastro-intestinal causes. He said that pathologically you cannot draw conclusions about what is happening in the stomach. He stated that there can be nausea and stomach pain in the absence of any endoscopic or radioscopic abnormality. Dr Stevenson stated that he could not see an impact on the gastro-intestinal sphincter in any of the studies for the SSRI class of antidepressant. Dr Stevenson perused Dr Cronin’s clinical notes which indicated that in August 1999 Dr Bowen suffered from gastritis and urticaria with Prozac. He stated that Dr Bowen may have had an allergic reaction to the Prozac that affected his stomach but that would be temporary and resolve within a few days, or at the most for a week or two, after he ceased taking the medication. He stressed that there would be no impact on the oesophageal sphincter.
35. In relation to Serzone, Dr Stevenson stated that it was removed from the market as there were some reports of liver failure with it. He said that the liver failure was not related to oesophagitis.
36. Dr Stevenson commented that the description of Dr Bowen’s condition as chronic active oesophagitis by Dr Wright following the gastroscopy would mean that it is likely that it was a long acting oesophagitis of an incompetent gastro-intestinal sphincter caused by habitual acid reflux over a protracted period. He said that the use of the term chronic would suggest that it is a long-lasting, constitutional condition due to the incompetent oesophageal sphincter rather than related to the commencement of Prozac in August 1999. He drew a distinction between acute oesophagitis and chronic oesophagitis. He stated that a comment by Dr Cronin in his evidence that Dr Bowen had suffered pains in his stomach whilst on various drugs over three or four years may simply have been evidence of his underlying gastro-intestinal pathology.
37. Dr Stevenson stated that most practitioners would use the smaller (monthly) MIMS on the desk to check on drugs that are prescribed occasionally. He stated that the larger Annual MIMS is a more inclusive, perhaps over-inclusive, document. He stated that MIMS is to a degree a legal document which lists all side effects that have been potentially linked, some of which may be significant and some of which may have been ascribed to it. Dr Stevenson said that he would prefer to use medical literature rather than MIMS. He commented that he had the same view about the manufacturer’s literature; as it, too, listed every effect that has potentially been linked to a drug. Dr Stevenson said that MIMS cannot be read in isolation, that it was not a cookbook but needed to be read by a clinician in the context of the known pharmacology and the literature.
38. Dr Stevenson stated that he agreed with Dr Reid in that he had not seen any links between antidepressant medication and oesophagitis, even if taken as an overdose. Dr Stevenson stated that the experience of physical pain does not necessarily correlate with the severity of oesophagitis and reflux. He said that the pain can fluctuate markedly with the patient’s psychiatric state because exacerbation of pain is a frequent symptom of depression.
Dr Walton
39. Dr Lester A Walton provided a psychiatric report dated 28 April 2005 (Exhibit R3). Dr Walton’s comments on the connection between the medication and the oesophagitis are:
5.Specifically in relation to the connection between the antidepressant medication and the onset of reflux symptoms/Barrett’s oesophagitis, that is a question worded with a degree of specificity placing it outside my area of expertise. As indication in the body of the report, it is not at all uncommon for patients being treated with antidepressant medications to complain of gastric distress. Very commonly such symptoms would fall well short of diagnosable reflux oesophagitis and, in my experience, the gastrointestinal symptoms are usually relatively easily managed by switching to an alternative antidepressant or adding in an antiulcer agent. In my clinical career to date, I have not encountered a patient who has gone on to surgical intervention on the specific basis of antidepressant-induced gastrointestinal symptoms.
CONSIDERATION OF THE ISSUES
40. In reaching its decision the Tribunal takes into account the written and oral evidence and the submissions made at the hearing.
41. The coroner determined that Dr Bowen’s death was due to haemorrhage following elective surgery. She made a number of recommendations as a result of her investigation concerning the development of guidelines on the availability of anaesthetists, surgeons and medical officers; storage of blood products on site and reminding nurses of the importance of complying with doctors’ orders and seeking advice when in doubt.
42. Dr Wright indicated in his reports that Dr Bowen had been referred to him for management of reflux oesophagitis. He stated that Dr Bowen also had a short segment of Barrett’s oesophagus and a small hiatus hernia. He stated that he had recommended anti-reflux surgery to Dr Bowen because of his intolerance to antidepressants and commented that in his opinion, there were no other remaining options for treatment. Because of the unavailability of Dr Wright and the death of Dr Bowen, there was no opportunity to find out the basis for Dr Wright’s comment that Dr Bowen had run out of all other options; or why he believed that the antidepressants were the cause of Dr Bowen’s reflux oesophagitis. No evidence was brought to the Tribunal’s attention that Dr Bowen had sought advice from other suitably qualified specialists as to any other viable treatments for his condition. Dr Bowen lodged a claim to have his condition accepted as work-related but that claim was rejected.
43. Mr White submitted that the reference in MIMS, to oesophagitis being a possible side effect of various SSRI antidepressants, was sufficient evidence to show a causal link between the drug and Dr Bowen’s oesophagitis. Dr Cronin and Dr Walton indicated that patients taking antidepressants suffered from gastric symptoms. However, neither of them had encountered another patient who needed surgery as a result of the gastric distress arising because of antidepressants. Dr Cronin stated that it was possible that the symptoms were independent of the antidepressants. Both psychiatrists conceded that they do not have the necessary expertise to determine whether the antidepressants led to the oesophagitis.
44. Dr Reid and Dr Stevenson indicated that MIMS is not a reliable reference for determining side effects of antidepressants as they believe that MIMS and the manufacturer’s literature lists any claimed side effects regardless of whether they are proven. MIMS was described as being akin to a legal document prepared to protect the pharmaceutical company from liability, rather than being the sound basis for diagnosis. Dr Stevenson commented that MIMS could not be used like a cook book. They cited other sources such as the Handbook as being more authoritative than MIMS. They also described their clinical experience and that of colleagues qualified in the area, none of whom thought that use of SSRI antidepressants could cause reflux oesophagitis.
45. The Tribunal prefers the evidence of Dr Reid and Dr Stevenson who have expert knowledge of the relevant condition. They were both adamant that the antidepressant medication could not cause or contribute to Dr Bowen’s oesophagitis. There was no evidence presented from any gastroenterologist to counter the evidence of Dr Reid and Dr Stevenson. The Tribunal gives Dr Wright’s reports lesser weight, as there is no indication as to the basis for his opinion on the link between the medication and the oesophagitis.
46. The Tribunal is not satisfied that Dr Bowen’s condition of oesophagitis and Barrett’s oesophagus constitute an injury or aggravation of an injury that was an unintended consequence of the antidepressants paid for by the Commonwealth. The Tribunal finds that Dr Bowen’s unfortunate death due to the haemorrhage following surgery does not meet the requirements of s 6A(2) of the Act
DECISION
47.The Tribunal affirms the decision under review.
I certify that the forty seven [47] preceding paragraphs are a true copy of the reasons for the decision of:
Regina Perton, Member
(sgd) Catherine Thomas
Clerk
Dates of hearing: 30 August 2005, 31 August 2005 and 10 October 2005
Date of decision: 30 March 2006
Counsel for applicant: Mr E White
Solicitor for applicant: KCI Lawyers
Counsel for respondent: Mr I Gourlay
Solicitor for respondent: Australian Government Solicitor
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