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Heather Saxena
A PATIENT who overdosed on tapentadol and oxycodone triggered 77 red flags in the real-time prescription monitoring system SafeScript , but doctors only checked his prescribing history on six occasions , a coroner has found .
Victorian Coroner Audrey Jamieson has criticised almost a dozen doctors for their prescribing , as well as the state Department of Health , saying it should have warned prescribers that they were breaking the law by not checking Safe- Script when required .
She was investigating the death of 46-year-old Bradley Liefvoort , who received a total of 988 tapentadol tablets and 1785 oxycodone tablets over six months .
He was found dead in June 2021 still “ clutching ” his medication , with boxes of
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S4 and S8 drugs sourced from 14 different pharmacies scattered around his apartment and in his car .
“ At the time of Bradley ’ s death , Safe- Script had already been compulsory to use for more than a year when prescribing or dispensing either of the two drugs that contributed centrally to the death : oxycodone and tapentadol ,” Ms Jamieson said .
“ I thought it very reasonable to expect that the clinicians involved in Bradley ’ s care — particularly in the months leading up to his death — should have been very familiar with the functioning of the SafeScript platform and its stated objectives .”
Two of the doctors were now under AHPRA investigation , she said .
But the fact that Mr Liefvoort received scripts from so many doctors suggested “ the SafeScript system either was not working as intended or was not
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being used as required by his prescribing clinicians ”.
While Mr Liefvoort ’ s drug dependence had started a decade earlier , the investigation focused on the six months leading up to his death when there was an “ escalation ” in his drug-seeking behaviour following the breakdown of his marriage .
Investigators found that 14 doctors had prescribed the drugs to Mr Liefvoort over this period , including 10 GPs across three practices , one hospital intern and one after-hours doctor .
But his SafeScript record had only been accessed six times — around one in every 13 prescriptions .
At least three GPs had received red alerts indicating that their patient had been prescribed the same drug by four or more doctors , or prescribed high-risk combinations of drugs , yet they failed to check the system .
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One said they were unable to access the SafeScript system until the next day because of a technical issue .
Another GP said that they did not “ recall any SafeScript warning at the
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