Finding into death of L I

Contributing factors

• prescription-shopping across 31 different doctors
• absence of mandatory real-time prescription monitoring at time of death
• lack of SafeScript checking by prescribers and dispensers
• prescription of opioids and benzodiazepines on one-off basis by doctors who did not make prior inquiries
• poor communication between general practitioner and child protection care team
• borderline personality disorder, factitious disorder, and opioid use disorder
• access to non-prescribed medications
• impulsive ingestion of multiple drugs
• multiple life stressors including relationship rejection and legal matters

Coroner's recommendations

1. The Australian Commission on Safety and Quality in Health Care should consider making compliance with real-time prescription monitoring a standard to be assessed under the National General Practice Accreditation Scheme
2. The Victorian Department of Health should develop, as a matter of priority, additional strategies to enhance oversight and compliance regarding SafeScript checking, including: (a) working with the Royal Australian College of General Practitioners, Medical Board of Australia, Pharmacy Board of Australia, medical indemnity insurers and other stakeholders to develop education and training tools that focus on positive benefits of SafeScript, reinforce its role as a clinical tool for the clinician's decision-making, and address perception that SafeScript usurps clinical judgment; (b) continuing to consider ways to surmount technological barriers to implementing SafeScript throughout hospitals in Victoria; and (c) continuing to work with Commonwealth Department of Health and Aged Care to implement cross-border data-sharing of real-time prescription monitoring
3. A copy of the findings should be provided to each GP who prescribed to LI on a short-term or one-off basis to ensure careful consideration of future prescribing and referral practices, particularly to young people presenting similarly
4. A copy of the findings may be provided to the DFFH/DoH working group considering improving outcomes for adolescents with a mental illness who are Child Protection clients and to any other Child Protection units that may benefit
5. A copy of the findings may be provided to the team contracted by DoH to undertake the five-year review into the SafeScript system
6. DFFH should consider the insights of LI's family and treating GP in future design of programs and training, including regarding communication with family members in kinship placements, coordination of complex services, and decisions about care team membership and frequency of communication with external health providers