It was incomprehensible how staff at an Adelaide pharmacy “morally and ethically” sold $500 worth of laxatives to a skeletal woman on a weekly basis, a psychiatrist has told a coronial inquest.
South Australian coroner Mark Johns is investigating the death of Claudia La Bella, 28, who died in June, 2014, from complications associated with laxative abuse.
For two years, the mother-of-one pretended to have terminal ovarian cancer to explain the symptoms she was suffering from taking up to 800 laxative tablets a day.
The inquest has heard staff at Chemist King at Hectorville would order 25 to 30 boxes of Dulcolax for Mrs La Bella every week, each of which contained 200 laxative tablets.
Mrs La Bella’s husband would make the weekly $500 orders on his wife’s behalf.
The inquest heard staff at the pharmacy had been told by Mrs La Bella and her husband that the laxatives were part of her cancer treatment and that no one questioned the legitimacy of the claims.
In her review of Mrs La Bella’s case, expert psychiatrist Maria Naso said she was astounded by the pharmacy’s actions.
“I still cannot comprehend how they morally and ethically sold someone up to $500 a week worth of laxatives,” she said.
“Just because they are not a regulated item does not mean we can forfeit our moral and ethical responsibility.”
Dr Naso questioned why a letter was not sought from Mrs La Bella’s doctor.
“It is hard to not see this as a purely financial transaction that was of benefit to the owner,” she said.
In her evidence, Dr Naso said it should raise a red flag if someone is buying $500 worth of vitamins, let alone laxatives, which are commonly known to be abused by people with eating disorders.
“I’m still astounded that this can occur,” she said.
“I know they are on the shelves … I know you can buy them online, however there’s a line that gets crossed when you’re putting in an order for boxes and boxes and boxes of laxatives week-in, week-out.”
“Selling that amount is beyond words, I’m sorry but it’s just beyond words, I can’t see how you can turn a blind eye to it.”
The retail manager of the pharmacy at the time, Jessica Cutting, told the inquest on Thursday she sought approval from pharmacist Carolyn Tan for the bulk orders.
However, Ms Tan told the court she was never asked about bulk orders of laxatives and if she had been she would not have allowed it.
Nine days before her death, Mrs La Bella was allowed to discharge herself from the Royal Adelaide Hospital, despite weighing just 35 kilograms, having no diagnosis, and a CT scan which showed dozens of tablets in her stomach.
The inquest heard the doctor who treated her, Paul Drysdale, urged her not to leave the hospital but decided against detaining her under an inpatient treatment order because she did not “appear to have a mental illness”.
Dr Naso said Mrs La Bella definitely should have been placed on a level one inpatient treatment order which would have ensured she was assessed by a psychiatrist within 24 hours.
“There is no reason why a psychiatric assessment has to wait for all of the [medical] investigations to be done, especially in the case of Mrs La Bella, where both the GP and medical staff had queried the possibility of anorexia nervosa,” she said.
“Discharging herself against medical advice indicates a serious lack of insight and judgment.
“She was willing to place herself at risk and leave her daughter potentially motherless — this itself should have raised grave concerns for her mental state.”
Dr Naso also criticised the doctor’s failure to speak to Mrs La Bella’s husband and mother separately at the hospital to ask further questions about Mrs La Bella’s presentation.
“If this had occurred it is likely that the history of ‘ovarian cancer’ and Mrs La Bella’s use of Dulcolax would have been discovered,” Dr Naso said.
The inquest heard after Mrs La Bella’s death her employer accused her of stealing $374,000 from them over five years.
“It was possible that Mrs La Bella got herself entangled. It is possible that she began embezzling and it’s very much a slippery slope,” Dr Naso said.
The court heard Mrs La Bella likely suffered from the factitious disorder Munchausen syndrome or a malingering disorder.
“The motive could have possibly been for her ‘oh gosh, I can’t be found out because I’m well aware this is fraud, I’m well aware I might end up in prison so perhaps I need to come up with something’,” she said.
Dr Nazo said Mrs La Bella had created an inescapable torment and her options were limited.
“She was embezzling money and had faked a terminal illness. She either had to die due to the illness, tell the truth or have a miraculous recovery, thus rousing family suspicions,” she said.
She said had Mrs La Bella been placed on a mental health order and diagnosed correctly she may not have died when she did.
“Long term, the treatment would have been complex but possibly with the support of family she may have been able to get into remission,” Dr Naso said.