Finding into death of James Stewart Dougan

Contributing factors

• Prescription shopping across multiple GPs
• Concurrent prescribing of benzodiazepines by multiple practitioners
• Inadequate monitoring of drug-seeking behaviour
• Prescription Shopping Program threshold too high to detect activity
• No real-time prescription monitoring system in Victoria
• Lack of communication between prescribing doctors
• Private script prescribing not captured in PBS records
• Absence of methadone treatment permit
• Severe coronary artery atherosclerosis (90% stenosis LAD)
• Polysubstance abuse with central nervous system depressants

Coroner's recommendations

1. Victorian Department of Health progress implementation of Victorian-based real-time prescription monitoring system as matter of urgency to prevent harms and deaths from pharmaceutical drug misuse
2. Victorian Department of Health identify legislative and regulatory barriers preventing Schedule 4 drugs (particularly benzodiazepines) being monitored in real-time prescription monitoring program and consider necessary reforms for future expansion beyond Schedule 8 drugs
3. Australian Government Department of Human Services review how Medicare Australia responds to Prescription Shopping Information Service queries to ensure medical practitioners understand limitations of the Service and that many drug seekers do not meet the Prescription Shopping Program threshold
4. Australian Government Department of Human Services introduce practice whereby when medical practitioner contacts Medicare Australia Prescription Shopping Information Service regarding Victorian patient, practitioner is informed that if concerns exist about patient being drug seeker regardless of Prescription Shopping Program status, notification should be made to Drugs and Poisons Regulation at Victorian Department of Health as required under Drugs Poisons and Controlled Substances Act 2006 (Vic)