Inquest into the death of Alissa Campbell

Contributing factors

• Prescription drug overdose—predominantly codeine and doxepin in combination
• Lack of real-time prescription monitoring allowing multiple doctors to prescribe without visibility of total medication load
• Doctor-shopping across 13 GPs in six months without coordinated care
• Use of private prescriptions bypassing PBS limits
• Failure of prescribing doctors to exercise independent clinical judgment and question patient requests
• Failure to recognise warning signs of problematic medication use and dependence
• Delay in recognition of overdose by household members and delayed emergency response
• Absence of substance abuse referral or treatment despite documented benzodiazepine dependence since 2010
• Complex psychosocial stressors and family dysfunction exacerbating anxiety and medication-seeking behaviour
• Large quantities of prescription drugs dispensed without adequate education about overdose risks

Coroner's recommendations

1. Urgent consideration should be given to raising the priority for introduction of Real Time Prescription Monitoring (RTPM) in NSW
2. The NSW Ministry of Health should plan and publish a timetable for the commencement of RTPM
3. Any future RTPM roll-out must extend beyond Schedule 8 drugs to include Schedule 4 drugs such as diazepam, codeine combinations, and tramadol which create serious problems especially when used in combination
4. RTPM must be compulsory and capture private prescriptions
5. All doctors prescribing opioids should explicitly discuss the dangers of overdose with their patients
6. General practitioners should receive more information and training in evidence-based non-pharmaceutical treatments for non-malignant pain
7. Processes and regulations surrounding prescription of drugs of dependency should be simplified and doctors further educated on these regulations
8. Increased awareness of naloxone should be promoted within the community and its distribution widened, including support for intranasal form currently before TGA
9. Public pain clinics should be better resourced