Last week, Victorian Coroner Ingrid Giles delivered a sincere, sensitive and considered finding following her investigation into the death of LI1, who died at the age of 16 in January 2019, as a result of mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlafaxine).2 LI was known to engage in 'prescription shopping' and, in the 12 months prior to his death, PBS records confirmed he had been dispensed 64 prescriptions provided by 31 doctors, in connection with 100 consultations.
Real-time prescription monitoring
Real-time prescription monitoring (RTPM) aims to reduce the risk of overdose or accidental death and other medication risks associated with controlled medicines3, by identifying and providing alerts to doctors and pharmacists prior to a medication being prescribed or dispensed, respectively.
Tasmania was the first State to introduce RTPM, with most other States and Territories launching their State based programs between 2019 – 2023.
RTPM is intended to:
- identify patients who are at risk of harm due to dependence or misuse of controlled medicines and use of contraindicated drug combinations
- identify patients who may be diverting controlled medicines
- limit 'prescription shopping' — visiting several doctors for the same prescriptions of a controlled medicine
- provide regulators with data to detect prescribers who are not complying with regulations.
RTPM allows access to information before the medication is prescribed, in a manner that is intended to minimise interference with or undermine the therapeutic relationship.
The case of LI – Coroner Giles's findings and recommendations4
LI had a complex history. He had been born opiate dependent due to his mother's drug dependency during pregnancy. He was subject to Child Protection reports from the age of 8 days until his death, including periods in foster care and living with different care arrangements throughout his life. He was diagnosed with ADHD, borderline personality disorder, factitious disorder, and opioid use disorder.
Between 2015 – 2019, he was admitted to hospital with indications of drug overdose and/or intentional self-harm and was admitted twice to an adolescent inpatient psychiatry unit in 2018, but released on referrals and into the care of his grandmother with referrals. He had, according to family members, feigned illness in order to receive medication since 2017. There was evidence that LI was prescribed medications for health conditions for which he had no diagnosis.
LI had a regular GP5 and was referred to various support services and his care team met regularly to collaborate in service delivery.
On Sunday, 27 January 2019, LI attended three GPs and was prescribed 20 tablets each of codeine, alprazolam and tramadol. He attended three pharmacies the following day to have the scripts dispensed. He died sometime between the evening of 28 January and the morning of 29 January 2019.
Expert evidence – drug seeking behaviours
Professor Edward Ogden6 provided expert evidence in the Inquest. He noted various red flags which ought to have alerted medical practitioners that LI was drug-seeking. Those factors were:
- He was unaccompanied by family or any other support person presenting with a 'serious medical condition';
- He refused permission to contact his family;
- He was identifying specific drugs by name and dose;
- He often presenting late in the day when his usual practitioner was unavailable;
- He travelled far from home to visit the practice; and
- He would present 'evidence' of his need for medication by showing poorly focused images of discharge summaries and other correspondence on an iPad.
Professor Odgen concluded that the appropriate response to LI's requests were for practitioners, before prescribing, to make further inquiries such as via Shopping Information Service, checking SafeScript, calling LI's usual doctor, and/or referring LI to an emergency department for acute care.
He went on to say that by without making enquiries before prescribing those these medical practitioners undermined the 'one-doctor-one-pharmacist' position, noting that while some GPs did record their suspicions regarding LI's motives for seeking prescriptions, they found it difficult to say 'no'. This impacted his regular GP, and LI's care team and family, who put much effort into curtailing LI's drug-seeking behaviour.
Key evidence
Coroner Giles recognised that at the time of LI's death, SafeScript7 was in its infancy; at the time relevant to LI was an 'opt in' basis.
Apart from hospital prescribers, it has been mandatory in Victoria since April 2020 to check SafeScript prior to writing or dispensing a prescription for controlled medicines8. Compliance is monitored daily by the Department of Health. Non-compliance identified by the Department of Health is managed however, by correspondence to the practitioner inviting a response that they are aware of their obligations. Referrals may be made to AHPRA by the Department of Health for practitioners who ignore correspondence from SafeScript or continue to prescribe medications without checking SafeScript. At inquest, there was evidence that compliance with SafeScript by clinicians prior to writing or dispensing a prescription was, in March 2024, only 70%. The representative of the Department of Health nominated two reasons for non-compliance; those who may not accept monitoring of practice by the State and overseas trained practitioners who may be unaware of it.
Coroner Giles' investigation also confirmed that only the worst 'offenders' would be referred to AHPRA for investigation and that the legal penalty has never been implemented. However, there is currently a legislative review underway to better enable penalties.
The inquest revealed gaps in the system given prescribers in hospitals are not required to check SafeScript in the hospital setting, and there is no federal RTPM. While there are current discussions to establish an Australia-wide RTPM service which would allow cross-border data sharing, this has been placed on hold until the 2025 financial year.
Publication and recommendations
Coroner Giles published her findings to a number of regulatory authorities and agencies, including the RAGCP, Medical Board, Pharmacy Board, AHPRA, Australian Commission on Safety and Quality in Health Care, Victorian Department of Health and the Commonwealth Department of Health and Aged Care.
Coroner Giles made recommendations to:
- Australian Commission on Safety and Quality in Health Care to consider making compliance with real-time prescription monitoring a standard to be assessed under the National General Practice Accreditation Scheme.
- Victorian Department of Health:
(a) To develop, additional strategies to enhance oversight and compliance of SafeScript and scope of application across the state, including by working with the RACGP, Medical Board and Pharmacy Board, medical indemnity insurers and other stakeholders, to develop education and training tools for clinicians promoting SafeScript as a clinical tool for the clinician's own decision-making, and address the perception among some clinicians that it usurps their clinical judgment
(b) Continuing to consider the ways in which to surmount technological barriers to implementing SafeScript throughout hospitals in Victoria; and
(c) Continuing to work with the Commonwealth Department of Health and Aged Care to implement cross-border data-sharing of real-timeprescription monitoring.
She also commented that her finding will be available to the team contracted by the Victorian Department of Health in its 5 year review of the SafeScript System9.
What next?
The parties the Coroner directed her recommendations to have 3 months to formally respond to those allegations. They need not accept them in full, but their position will become known in due course when their responses are published by the Coroners' office.
Implications for practitioners
With the referral of Coroner Giles' findings to the relevant Boards and AHPRA, as well as the reference to better enabling the imposition of the penalty under State legislation, practitioners in Victoria who are not routinely aware or compliant with their obligations to check SafeScript should to ensure it becomes a foundation to their prescribing/dispensing practices.
Increased education and communication from relevant authorities might also follow.
The findings offer risk management opportunities to insurers of relevant practitioners.
The finding also serves a timely reminder of prompts or flags for practitioners connected with drug seeking behaviours by people present well and are polite. While some are specific to LI's age (with respect to involving others in his care), the finding is a timely reminder of the need to exercise caution and derive confidence in prescribing offered to them by the RTPM in their own State or Territory.
Such a practice can save patients from significant harm and help facilitate the provision of best care.
Foonotes
1 A pseudonym
2 Finding into death with Inquest – COR 2019 0537 – for publication.pdf (coronerscourt.vic.gov.au)
3 Each State and Territory has is own defined medications that are 'controlled substances' but they include certain analgesic medications and benzodiazepines
4 The inquest covered other issues concerning the child protection case management which this summary does not address, unless relevant.
5 Whose care Coroner Giles identified as 'above and beyond what you'd expect of most general practitioners'
6 Fellow of the Royal Australian College of General Practitioners, Fellow of the Chapter of Addiction Medicine of the Royal Australian College of Physicians, and Fellow of the Faculty of Clinical Forensic Medicine of the Royal College of Pathologists of Australasia
7 Victoria's software program via the Department of Health.
8 The penalty for not doing so is 100 penalty units (which is currently $19,231); Drugs, Poisons and Controlled Substances Act 1981
9 Due to be finalised this financial year
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