Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Contributing factors

• doctor shopping - seeing multiple doctors to obtain excessive medications
• lack of real-time prescription monitoring system
• failure to communicate between prescribers
• failure to communicate between prescribers and pharmacists
• prescribing benzodiazepines long-term despite contra-indications and addiction risk
• prescribing opioids to substance-dependent patients
• prescribing psychiatric medications without psychiatric consultation
• emergency department lack of access to full patient history
• fragmentation of care across multiple medical services
• inadequate assessment before initiating addictive medications
• pharmacy failure to refuse dangerous dispensing
• pharmacy failure to maintain clinical notes
• inappropriate combination prescribing (tramadol with serotonergic antidepressants, benzodiazepines with opioids)
• inadequate medical record keeping by doctors
• false claims of lost prescriptions and trips not followed up
• escalating medication doses without clinical justification

Coroner's recommendations

1. Move all benzodiazepines to Schedule 8 of the Uniform Scheduling of Medicines and Poisons
2. Implement real-time web-based prescription monitoring program available to pharmacists and GPs within 12 months recording all Schedule 8 dispensing and providing real-time information
3. Include all benzodiazepines in the real-time prescription monitoring system
4. Educate pharmacists and GPs on reporting inappropriate prescribing and identification methods
5. Require doctors to verify prescribing history before commencing Schedule 8 drugs or benzodiazepines; if not practicable, limit supply to essential amounts until history obtained
6. Expand restrictions on Schedule 8 drug prescribing to include restricted drugs of dependence
7. Pharmacy Guild develop de-identified case studies on prescription misuse for continuing education
8. Pharmacy Guild, Pharmaceutical Society and RACGP collaborate on promoting staged supply, supervised administration, and education modules on responding to suspected medication misuse
9. RACGP develop 1-2 page clinical guideline covering chronic non-cancer pain management, benzodiazepine prescription, opioid prescription, private and repeat prescription appropriateness, and available resources
10. RACGP develop clinical governance framework for General Practices addressing prescription drug abuse
11. RACGP and NCIS liaise on sharing information about prescription medication-linked deaths
12. RACGP require all GPs prescribing Schedule 8 or benzodiazepines to attend skills training within 3 years on pain management, drug dependency, and opioid/benzodiazepine prescribing
13. Include education module addressing information sharing and legal constraints in continuing professional development
14. RACGP establish local forums for GPs, pharmacists and specialists to identify doctor shopping patterns and establish communication channels
15. Medicare work with Pharmaceutical Society and Pharmacy Guild to facilitate pharmacist access to prescription hotline
16. Make registration under Prescription Shopping Program compulsory for all medical prescribers
17. Review efficacy of Prescription Shopping Program and improve prompt identification of medication abuse
18. Commonwealth and NSW Health require GP consultation with psychiatrist before prescribing long-term anti-depressant or anti-psychotic medications except in exceptional circumstances