Finding into death of Karen Ann Moore

Contributing factors

• High-dose oxycontin and diazepam prescription without consistent monitoring
• Failure to implement specialist pain review as required by permit conditions
• Inadequate communication and coordination between GP and hospital
• Inconsistent attempt to reduce benzodiazepine dosage
• GP unaware of multiple overdose admissions
• Evidence of intravenous drug use not adequately addressed
• Possible fraudulent prescriptions on GP's prescription forms
• Lack of real-time prescription monitoring system
• Patient dependency on opiates and benzodiazepines not effectively managed

Coroner's recommendations

1. Implementation of Victorian real-time prescription monitoring system to prevent drug-seeking and overuse behaviours
2. Encourage Royal Australian College of General Practitioners to continue education on responsible prescribing of drugs of dependence
3. Therapeutic Goods Administration to re-schedule all benzodiazepines as Schedule 8 drugs
4. Development and implementation of computer-aided systems to manage 'doctor shopping' and 'pharmacy shopping'
5. GPs to establish who else is prescribing benzodiazepines and other relevant drugs, particularly Schedule 8 opioids
6. Mandatory specialist pain management review prior to renewal of Schedule 8 prescribing permits
7. Improved coordination between GPs and hospital services regarding overdose admissions and medication management