Coroner's Finding: Stocks, Michelle Jayne

Contributing factors

• Inadequate risk-benefit assessment of high-risk polypharmacy regimen
• Failure to verify prescriptions from Queensland treating doctors
• Reliance on unverified handwritten medication list from patient
• Over-reliance on pharmacy approval without adequate clinical due diligence
• Lack of specialist consultation for complex pain management
• Patient's practice of hoarding medications
• Patient's inconsistent medication adherence
• Patient's underlying lung disease increasing vulnerability to CNS depression
• Alcohol consumption combined with CNS depressants

Coroner's recommendations

1. Dr Q should have conducted a more thorough risk-benefit assessment of the high-risk polypharmacy regimen before issuing prescriptions
2. Dr Q should have independently verified prescriptions from Queensland treating doctors rather than relying on a handwritten list presented by the patient
3. Dr Q should have contacted Queensland's Drugs of Dependence Unit to confirm details of any Schedule 8 medicine supplies
4. Pharmacy approval should not be treated as a substitute for adequate clinical due diligence by the prescribing doctor
5. Specialist consultation should have been sought for complex pain management cases
6. Staged supply of medications should have been considered for high-risk regimens
7. Greater caution should be exercised when treating patients after significant gaps in care or when resuming complex medication regimens without independent verification