Finding into death of David Andrew Trengrove

Contributing factors

• Prescription shopping across multiple doctors
• Absence of real-time prescription monitoring system
• Excessive prescribing of benzodiazepines by Dr L.
• Lack of communication between prescribing doctors
• Benzodiazepine dependency and likely contribution to respiratory depression
• Increased morphine dosing in months prior to death
• Inadequate prescribing guidelines for benzodiazepines
• No requirement for periodic specialist review of long-term opioid therapy
• History of substance abuse and steroid use
• Mental illness with schizophrenia and depression

Coroner's recommendations

1. The Victorian Department of Health implement a real-time prescription monitoring system within 12 months that is readily accessible via internet to prescribers and dispensers during consultations to check patient histories and make informed prescribing decisions on the spot
2. The Royal Australian College of General Practitioners update its benzodiazepine prescribing guidelines within 12 months to address: general principles for prescribing, appropriate use for specific conditions, strategies to identify patients seeking excessive benzodiazepines, and management of risk of harm and death
3. The Therapeutic Goods Administration move all benzodiazepines into Schedule 8 of the Standard for the Uniform Scheduling of Medicines and Poisons within 12 months to reduce harms and deaths associated with benzodiazepine use
4. The Chair of the RACGP Victoria Faculty advise the Coroners Court within three months regarding progress on developing guidelines for general practitioners prescribing opioids for chronic non-malignant pain, scope of areas to be addressed, hurdles hindering completion, and proposed timeline
5. Drugs and Poisons Regulation at the Victorian Department of Health consider requiring that where a practitioner prescribes a Schedule 8 poison for chronic non-malignant pain on a long-term basis, evidence must be submitted that the patient has been periodically reviewed by a pain specialist to ensure appropriate expert evidence-based care and reduce inappropriate exposure to Schedule 8 poisons