Graham, Travis Noel

Contributing factors

• Prescription for Seroquel recorded as ceased but not actively cancelled with Health Insurance Commission
• No system in place to prevent duplicate prescriptions across multiple pharmacies
• Prescriptions filled at two different locations within three weeks without pharmacist awareness
• Doctor did not notify patient to return prescription or destroy repeats after cessation
• Lack of communication between prescribing doctor and new general practitioner regarding active prescriptions
• Large packet sizes (60 tablets per packet) allowing accumulation of lethal doses
• Patient's history of suicide attempts and overdoses not adequately considered in prescribing decisions

Coroner's recommendations

1. The drug Seroquel be packaged, marketed and supplied in packets of 30 to protect against lethal doses of the medication being easily available to vulnerable members of society.
2. A national database containing dispensing histories for all patients be developed to enable pharmacists to identify over-dispensing of prescription medication, with facility to raise an alert if the same prescription medication has been dispensed by any pharmacist to the same patient within a short period of time.
3. Federal privacy laws be amended to enable PBS information about a patient to be disclosed to the approved supplier of medication to that patient.
4. Where concerns are raised with regard to authority prescriptions or such prescriptions are to be cancelled or withdrawn, that prescribing medical practitioners immediately advise the Health Insurance Commission, so that an alert can be raised on the Health Insurance Commission database which is available to all pharmacists in real time when dispensing medications.
5. A process be developed to ensure that prescriptions which have been cancelled or withdrawn by a treating medical practitioner are returned to the medical practitioner or destroyed, to prevent such prescriptions from being presented by patients to be dispensed.