Inquest into the Death of Shayne Andrew BERRY

Contributing factors

• Registered drug addict status not accessible in real time to prescribers
• Registered drug addict status not disclosed by patient to prescribers
• Reduced opioid tolerance after 21 months without opioid replacement therapy
• Heavy benzodiazepine use (diazepam prescribed for bipolar disorder and anxiety)
• Intravenous injection of multiple times the prescribed dose
• Concurrent sedating medications (amitriptyline, quetiapine, diazepam)
• Obesity and likely obstructive sleep apnea
• Evidence of aspiration of vomit
• Absence of authorised CPOP prescriber in Karratha in 2011 led to lapse of opiate substitution program
• Information about drug addict registration on file was lost and not readily accessible to treating doctors
• Inability to access drug addict register in real time from different pharmacies

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 the supply or dispensation of all Schedule 8 and reportable Schedule 4 poisons are recorded in the secure regulated database held by the WA Government regulator
4. WA regulate to provide both prescribers, registered pharmacists and authorised suppliers access to that secure data via secure software links to facilitate real time decision making around both prescribing, supplying and dispensing of Schedule 8 and reportable Schedule 4 poisons
5. The current Schedule 8 (controlled drug) dependency register be part of that secure database and provide that information along with real time information about medicines dispensed on enquiry by a prescriber, registered pharmacist or authorised supplier
6. The information from any register regulated (e.g. reportable Schedule 4 poisons) as part of the secure database, be similarly available on enquiry for dispensed medicines
7. Once real time WA dispensing data is available for use there be a regulated time period to allow commercial practice case management software to be developed to facilitate real time access. Once that period is over it be regulated that prescribers access the available data prior to completing any prescription or supply for Schedule 8 or reportable Schedule 4 poisons
8. All benzodiazepines be included as reportable Schedule 4 poisons
9. There be a method implemented to assist prescribers and dispensers with decision making around benzodiazepine dependency, and restrictions imposed on recognised unsafe prescribing or supply
10. CPOP prescribers be given information about a patient's prior CPOP programs and prescribers when seeking authorisation to commence a new program
11. CPOP prescribers to provide advice when seeking authorisation as to other medications to be prescribed in conjunction with the authorised program medicine, including reportable Schedule 4 poisons and amounts with intended reduction regime
12. The ultimate aim for the secure regulated database held by the WA Government regulator be for all prescription medicines to be captured
13. The ultimate aim for real time ERRCD data should be for Australia wide access to dispensing data for medical practitioners, registered pharmacists and authorised suppliers