Coroner's Finding: Steer, Michael Allan

Contributing factors

• cessation of controlled medication dispensing regime
• unsupervised access to prescription medications
• ingestion of excess quetiapine, codeine, diazepam, fluoxetine
• underlying cardiomegaly and cirrhosis
• complex psychiatric history with factitious and somatic disorders
• documented history of drug-seeking behaviour
• failure of neighbours to seek emergency medical assistance
• inadequate specialist addiction assessment and monitoring

Coroner's recommendations

1. Amend Poisons Regulations 2008 Regulation 70 to require specific authorisation from the Secretary to prescribe high-abuse-potential drugs (benzodiazepines, z-drugs, pregabalin, quetiapine) where patient has been reported or diagnosed as drug dependent or drug seeking
2. Review real-time monitoring system (DORA) to include mandatory recording of dispensing of Schedule 4 drugs of high abuse potential at time of dispensing
3. Create position of Outreach Clinical Educator within PSB to provide education to prescribers and dispensers regarding appropriate practice for Schedule 8 and Schedule 4 high-abuse-potential drugs, and encourage DORA uptake
4. Develop revised section 59E application form requiring comprehensive information and evidence-based risk/benefit assessment of requested Schedule 8 regimens
5. Review Poisons Act 1971 (nearly 50 years old) with view to creating new contemporary Act aligned with modern regulatory practices