Finding into death of Anne Christine Brain

Contributing factors

• Absence of real-time prescription monitoring system in Victoria
• Prescription shopping from seven different general practitioners
• Lack of communication between treating clinicians
• Inability of clinicians to access medication history from other prescribers
• Privacy regulations preventing information-sharing between prescribers
• Dangerous polypharmacy combining benzodiazepines with opioids
• Complex mental health history with multiple medications

Coroner's recommendations

1. The Victorian Department of Health progress implementation of a Victorian-based real-time prescription monitoring (RTPM) system as a matter of urgency to prevent ongoing harms and deaths associated with pharmaceutical drug misuse and inappropriate prescribing and dispensing
2. While implementing RTPM for Schedule 8 drugs, the Department of Health identify legislative and regulatory barriers preventing monitoring of drugs in other schedules, particularly Schedule 4, and consider necessary reforms to expand the program beyond Schedule 8 drugs to enhance clinicians' ability to make appropriate clinical decisions
3. The Victorian Department of Health consider meeting with private health information technology developers and vendors to discuss and address legislative and regulatory barriers that might prevent private companies providing real-time prescription monitoring capacity through their products and services