House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Contributing factors

• doctor shopping—obtaining controlled drugs from multiple prescribers concurrently
• absent real-time prescription monitoring system
• fragmentation of health information between community and hospital providers
• inadequate clinical screening for opioid dependence and drug-seeking behaviour
• inappropriate prescribing of opioids at high doses for conditions not suitable for opioid therapy
• failure to communicate drug-dependence concerns between healthcare providers
• lack of integrated care planning across multiple specialists and general practitioners
• delayed regulatory oversight and non-timely alerts to prescribers
• insufficient general practitioner education on opioid prescribing and regulatory obligations
• absence of structured communication protocols between hospital discharge and general practice
• inadequate resources for monitoring and enforcement by regulator (MRQ)

Coroner's recommendations

1. Queensland Department of Health to urgently implement real-time prescription monitoring system (ERRCD or alternative hybrid system) within two years; determine suitability of ERRCD without delay; develop business plan and secure appropriate funding as priority; plan transition to operational system within two years in line with other Australian states
2. Queensland Department of Health to urgently educate general practitioners and pharmacists on scope, functions, and availability of MRQ advice; implement professional disciplinary action for over-prescribing of opioids once education campaign completed
3. Queensland Department of Health to review adequacy of resourcing provided to MRQ to perform regulatory functions proactively, particularly given new S8 Monitoring Strategy timeframe changes
4. Commonwealth Department of Health to liaise urgently with all state governments to accelerate national introduction of ERRCD
5. Commonwealth Department of Health to consider legislating ban on promotion of prescription opioids to health practitioners by drug manufacturers
6. Royal Australian College of General Practitioners (RACGP) to urgently introduce or expand continuing professional development programs to improve education and standards of care in prescribing of Schedule 8 medicines and chronic pain management
7. Pharmacy Guild of Australia, Pharmaceutical Society of Australia, and RACGP to collaborate on promoting staged supply and other harm reduction measures to reduce misuse of prescription medications