Hamilton homicide detectives want inquest into four-year-old’s overdose death

Hamilton homicide detectives are calling for an inquest into the overdose death of a four-year-old boy after complaining to the regulatory colleges of both the doctors and pharmacy where Kane Driscoll's mom was accessing prescription narcotics.

A four-year-old died and he has no voice," said Det. Sgt. Peter Thom, of the major crime unit. He should be an active seven-year-old now and he was robbed of that."

Driscoll was found dead in his family's Hamilton Mountain home on the morning of Sept. 27, 2017. He had just started junior kindergarten and had overcome a number of health issues in his short life. At first it was not clear how he died, but months later, toxicology results showed he died of hydromorphone poisoning.

Thom was the case manager on the homicide investigation where Driscoll's mom, Lisa Strickland, was eventually charged with manslaughter. This January, she pleaded guilty to criminal negligence causing death and was handed a two-and-a-half year sentence.

Court heard the hydromorphone - a powerful opioid - had been prescribed to her in increasing amounts in the lead-up to her son's death. But it's not clear how the boy ingested the drugs.

The more they investigated the case, the more police became concerned about the seeming lack of regulation into how much Strickland was being prescribed. Police sent complaints to both Ontario's College of Physicians and Surgeons and the College of Pharmacists.

Thom said the results of those investigations - both which recommended little more than re-education - were confounding.

It's astonishing that there wasn't any more accountability placed on either the prescribing doctors or the pharmacy," he said.

In the month leading up to the four-year-old's death, Strickland, a former nurse, travelled from Hamilton to 790 Bay St. in Toronto eight times. She saw two doctors - Dr. Ilan Shahin and Dr. Matthew Friszt - at Bay College Medical and Lockwood Diagnostic and filled all prescriptions at Bay College Drug Mart. In all, she accessed 800 hydromorphone tablets, a mix of one- and two-milligram doses.

A review by Dr. John Fernandes, a well-respected forensic pathologist who died in 2019, found she was prescribed hydromorphone at eight times the normal amount. He concluded that Strickland, on medical leave for multiple painful ailments including peptic ulcers, did not require that level of narcotics.

Yet a summary of the college's investigation into pharmacist Wafaa Boshara - the designated manager of Bay College Drug Mart - said the amount of medication was not a red flag.

An expert opinion obtained by the panel indicated that the quantities prescribed were under the dose which would be a red flag in combination," reads the summary of the committee's decision dated Sept. 29, 2020, but not posted online until this week.

The panel felt that as the dose was not an issue according to the expert, and since the patient was being monitored while the medications were prescribed concurrently, Ms. Boshara did not dispense the medications inappropriately."

According to the document, Boshara said all prescriptions were appropriately assessed" and there was no indication that staff should have refused to dispense the prescriptions."

However, the committee said the pharmacy should have had conversations with the patient about her medication and documented those conversations.

The patient was dispensed significant quantities of narcotic medications and (the panel) felt that Ms. Boshara and her staff took too passive a role in dispensing and ensuring their appropriate use," the document said.

The panel felt Boshara and her staff dispensed narcotics with little thought as to whether this was the best therapy for the patient ... The panel emphasized that the patient's well-being cannot be solely left in the hands of the prescribers."

Boshara was ordered to complete two programs on safe opioid prescribing and proper documentation within a year, at her own expense. Once complete, she must appear before the panel for an oral caution and so the panel can talk to her about what she's learned.

The most serious cases before the college go to the disciplinary committee. That did not happen in this case.

The Spectator has previously reported the doctors were required to undergo training around opioid prescribing after similar investigations.

Neither the doctors nor the pharmacist have responded to requests for comment from The Spectator.

It was after reading the latest decision by the College of Pharmacists that Thom said the homicide detectives on the case decided to appeal for more to be done.

I emailed the regional coroner expressing my dismay at the results of both the colleges' findings and I thought it would be prudent for them to have an inquest," he said.

That email was sent Wednesday morning and there has not yet been a response. Coroner's inquests examine deaths and can make recommendations to prevent similar deaths in the future.

Stickland's failure to keep her medication away from her son is what caused Driscoll's death, but Thom said there are circumstances leading up to his death that contributed. Both lawyers and the judge made similar remarks about shared blame during Strickland's hearing.

On Sept. 11, 2017, Stickland told Dr. Shahin she wanted to go off hydromorphone because it was making her careless," court heard. She had put her phone in the fridge.

She was prescribed codeine, but came back on Sept. 18 for more hydromorphone. There were no barriers to her accessing more medication.

Nine days later, the four-year-old was found lifeless in his bed.

Nicole O'Reilly is a Hamilton-based reporter covering crime and justice for The Spectator. Reach her via email: noreilly@thespec.com