Inquest into the Death of Adrian Marcus WESTLUND

Contributing factors

• Prescription drug-seeking behaviour and manipulation of multiple prescribers
• Lack of real-time dispensing information preventing detection of concurrent prescriptions from multiple practitioners
• Patient's false reporting of benzodiazepine tolerance to obtain escalating doses
• Patient's alleged but unverified heroin use used to justify methadone registration
• Benzodiazepine dependence not registrable under Schedule 8 addiction register
• Multiple GPs unaware of each other's involvement
• Refusal to accept inpatient management or daily dispensing
• Excessive benzodiazepine prescriptions (500mg diazepam equivalent daily)
• Co-prescription of benzodiazepines and opioids with synergistic respiratory depression
• Patient stockpiling benzodiazepines from multiple sources

Coroner's recommendations

1. WA prioritise the real time collection of dispensing data from all pharmacies for all Schedule 8 and reportable Schedule 4 poisons
2. All WA real time dispensed medicine data be held in a secure regulated database held by the WA government regulator
3. WA regulate to ensure supply or dispensation of all Schedule 8 and reportable Schedule 4 poisons are recorded in the secure regulated database
4. WA regulate to provide prescribers, registered pharmacists and authorised suppliers access to secure data via secure software links for real time decision making
5. Current Schedule 8 dependency register be part of secure database with real time information about dispensed medicines on enquiry
6. Information from any register regulated as part of secure database be available on enquiry for dispensed medicines
7. Regulated time period to allow commercial practice software development, then require prescribers access available data prior to completing any prescription for Schedule 8 or reportable Schedule 4 poisons
8. All benzodiazepines be included as reportable Schedule 4 poisons
9. Method implemented to assist prescribers and dispensers with decision making around benzodiazepine dependency with restrictions on unsafe prescribing or supply
10. CPOP prescribers be given information about patient's prior CPOP programs and prescribers when seeking authorisation
11. CPOP prescribers provide advice when seeking authorisation as to other medications to be prescribed with authorised medicine, including reportable Schedule 4 poisons and amounts with intended reduction regime
12. Ultimate aim for secure regulated database be for all prescription medicines to be captured
13. Ultimate aim for real time ERRCD data should be Australia wide access to dispensing data for medical practitioners, registered pharmacists and authorised suppliers