Finding into death of Bradley Scott Liefvoort

46y · Male·Opioid toxicity (tapentadol and oxycodone)

Bradley Liefvoort, 46, died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence following gastrointestinal issues. Critical clinical failures in the final six months included: multiple prescribers issuing large quantities of Schedule 8 opioids without mandatory SafeScript checks (legal requirement since April 2020), absence of valid permits required by law for opioid prescribing to dependent patients, and inadequate coordination between prescribers. Toxicology showed lethal-range opioid levels. The coroner found that checking SafeScript—which would have revealed concerning prescribing patterns and alerts—and obtaining required permits presented multiple opportunities to intervene. The Department of Health failed to act on real-time SafeScript data despite their visibility of non-compliance. Systemic failures by both individual prescribers and regulatory authorities contributed directly to preventable death.