Finding into death of Rory Brett Denman

Contributing factors

• prescription shopping from 19 different doctors
• lack of real-time prescription monitoring system
• absence of coordination between prescribers
• chronic pain management inadequately supervised
• alcohol use disorder with recurrent pancreatitis
• apparent medication misuse
• multiple CNS depressants prescribed concurrently

Coroner's recommendations

1. The Victorian Department of Health implement a real-time prescription monitoring program within 12 months to reduce deaths and harm associated with prescription shopping, with focus on public health rather than law enforcement, recording all prescription medications prescribed and dispensed throughout Victoria, provision of real-time prescribing information via internet to all prescribers and dispensers, and support for clinical decision-making
2. The Victorian Department of Health convene a steering committee to oversee implementation of the real-time prescription monitoring program with representatives from prescribing and dispensing peak bodies and the pain management and drug and alcohol sectors
3. The Victorian Department of Health develop a contingency plan to implement a Victorian-based real-time prescription monitoring program in the event that the anticipated Australian Government Department of Health and Ageing IT infrastructure is delayed more than six months beyond July 2012 deadline
4. The Victorian Department of Health develop a contingency plan to implement a Victorian-based real-time prescription monitoring program in the event that the anticipated Australian Government Department of Health and Ageing IT infrastructure does not support required functionality including public health focus, comprehensive medication recording, real-time information provision, and support for clinical decision-making