Finding into death of Dean Wayne Wright

Contributing factors

• prescription shopping across multiple medical clinics and doctors
• lack of real-time prescription monitoring system
• delayed notification of prescription shopping alert (two-and-a-half month lag)
• fragmented medical care with poor information sharing between prescribers
• inadequate clinician understanding of obligations under DPCS Act section 33
• concurrent prescribing of benzodiazepines and opioids
• systematic use of multiple pharmacies to dispense prescriptions
• clinician reliance on patient statements about lost prescriptions
• lack of coordination between multiple prescribers in multi-doctor clinics
• absence of comprehensive safety checks at time of prescribing

Coroner's recommendations

1. Victorian Department of Health progress implementation of a Victorian-based real-time prescription monitoring system as a matter of urgency to prevent ongoing harm and deaths associated with pharmaceutical drug misuse and inappropriate prescribing and dispensing
2. Victorian Department of Health identify legislative and regulatory barriers that might prevent drugs listed in other schedules (particularly Schedule 4) from being monitored within a real-time prescription monitoring program, and consider what reforms are necessary to expand monitoring beyond Schedule 8 drugs
3. Royal Australasian College of General Practitioners consider including and/or enhancing a section in its Standards for General Practices to inform and advise general practitioners about their legal obligations when prescribing medications, especially those arising from section 33 of the DPCS Act, and provide professional development opportunities relating to safe prescription of drugs of dependence
4. Royal Australasian College of General Practitioners remind its members about the Prescription Shopping Information Service and encourage its use whenever there are concerns that a patient may be abusing prescription medications, as it provides information current to up to 24 hours