Finding into death of Kirk Ardern

Contributing factors

• takeaway methadone dispensing two days after prison release without stability assessment
• prescription of diazepam without checking for concurrent methadone treatment
• lack of fixed accommodation post-release
• combination of benzodiazepines and methadone increasing overdose risk
• decreased opioid tolerance following enforced abstinence in prison
• inadequate communication between prescribers
• heroin use while on methadone
• recent release from prison (known high-risk period for overdose)
• poly-substance use
• lack of specific Department of Health guidance for recently paroled patients
• no real-time prescription monitoring system to prevent prescription shopping

Coroner's recommendations

1. The Victorian Department of Health should amend the January 2013 Policy for Maintenance Pharmacotherapy for Opioid Dependence to incorporate explicit advice on managing vulnerable opioid replacement patients including those recently paroled from prison, indicating that a client transferred from prison to community-based service should be treated as a new patient commencing treatment and should not be provided takeaway doses until medical, psychological and social stability in the community is established.
2. All benzodiazepines should be rescheduled from Schedule 4 to Schedule 8 (not just alprazolam) because they present the same risks as alprazolam and diazepam is the most frequent contributing benzodiazepine in Victorian overdose deaths.
3. The Victorian Department of Health should explore options for implementing a Victorian-based real-time prescription monitoring system to prevent ongoing harms and deaths associated with pharmaceutical drug misuse and inappropriate prescribing and dispensing.
4. The Victorian Department of Health should create and maintain a page on its website within three months regarding real-time prescription monitoring, the ERRCD system and related topics, providing up-to-date information regarding planning and implementation of this public health initiative.
5. The Royal Australian College of General Practitioners should update benzodiazepine prescribing guidelines (last revised 2000) to address the context of general practice including identification and management of patients seeking excess benzodiazepines, and should provide mandatory training for GPs on safe benzodiazepine prescribing.
6. Medical training should be enhanced to provide undergraduate, professional and mandatory ongoing education on best practice benzodiazepine and opioid prescribing, including risk assessment, alternatives to pharmacotherapy, and interdisciplinary communication.
7. Pre-release discharge planning in prisons should include education on naloxone for overdose response and the importance of educating suitable partners/friends in overdose response.