Coroner's Finding: de-identified UN

Contributing factors

• inappropriate prescribing of high-risk medications by general practitioner
• excessive quantities of pregabalin and temazepam dispensed on consecutive days at different pharmacies
• unnecessary duplicate prescriptions issued on 3 April 2023 while patient was hospitalised
• patient's known history of opioid use disorder and drug-seeking behaviour not adequately managed
• lack of risk mitigation strategies including staged supply or urine drug screening
• patient's injection of partner's methadone in combination with prescribed medications
• absence of awareness by prescriber that patient was hospitalised at time of consultation

Coroner's recommendations

1. General practitioners and pharmacies should take all appropriate risk mitigation strategies when prescribing high-risk medications to patients with drug dependency or known medication misuse
2. Conduct frequent risk assessments for patients with opioid use disorder including unannounced urine drug screens and checking for signs of injecting drug use
3. Undertake and document risk-benefit assessments to ensure judicious use of high-risk substances in opioid use disorder
4. Consider staged supply of medication as a clinical management tool for high-risk patients, involving structured pharmacist service with instalment supply
5. Verify patient hospitalisation status before prescribing, particularly for patients with substance use disorders
6. Implement real-time prescription monitoring systems such as TasScript to prevent dispensing of duplicate prescriptions at different pharmacies