a month to AHPRA .

Not all of them end up dragged

before a tribunal to account for their

sins , but the notifications are being

made for ignoring warnings to check

patients ’ prescription history before

prescribing high-risk drugs .

The Victorian Department of Health

revealed the scale of its activities during

a recent coroner ’ s inquest into the

As a result of his efforts , he was dis-

was still a work in progress , with cli-

In cases where the doctor fails to

clinicians who fail to check Safe-

death of a 16-year-old , whose body

pensed 64 PBS scripts by 31 different

nicians checking the software 70 % of

respond and continues not to check

Script — and that only a tiny propor-

was found at his grandmother ’ s house

doctors , arising from more than 100

the time when required .

the system , the department then noti-

tion of those referrals appear to have

where he had been living . A search of the bedroom found an empty vial of oxycodone – naloxone

consults . Coroner Ingrid Giles said doctors had described him as “ charismatic

Grave concern

Laura Mulligan , the state health

fies AHPRA . “ We wouldn ’ t notify about every single clinician [ who is ] not checking

resulted in any action in relation to practitioners acting unlawfully since SafeScript was made mandatory in

( Targin ), an empty blister packet of

and polite ”, but she suggested his

department ’ s director of regula-

the system , or we ’ d be notifying about

April 2020 — is of grave concern .”

codeine and an uncapped needle with

youth may have lessened suspicions

tory services , suggested the lack of

many , many thousands of clinicians ,”

Ms Giles asked whether SafeScript

no syringe attached .

he was doctor-shopping .

engagement may be the result of a

Ms Mulligan said .

would have saved the life of the boy

The toxicology reports traced

It is important to state here that all

desire by doctors not to be monitored

“ So we send a list of sort of roughly

whose death was the subject of her

codeine , morphine , tramadol , alpra-

this occurred before SafeScript — the

or have their clinical practice over-

between 10 and 30 each month to

inquest .

zolam and desmethylvenlafaxine in

real-time prescribing system — was

seen by the state .

AHPRA .”

That is a tough question .

the boy ’ s blood .

fully up and running in Victoria , along

“ She also noted that there are dif-

Since April 2020 , when checking

Can it ever really prevent all future

A sadly familiar story

The narrative arc in his short life will

be familiar enough to doctors : a difficult upbringing , time in foster care , complex mental health problems , a borderline personality disorder diagnosis .

There were numerous suicide attempts , and at one stage , he was also swallowing batteries , coins , chains , screws , staples and , in the weeks before his death , a hypodermic needle , which required hospitalisation and endoscopic removal .

The inquest was told that his regular GP had tried her best to care for him . But it was clearly close to

with laws to prosecute those doctors and pharmacists not checking previous scripts written and dispensed .

But at the inquest , Professor Edward Ogden , an addiction specialist , listed the red flags :

• The boy was unaccompanied by any family member despite presenting with a serious medical condition .

• He refused permission to contact his family .

• He specified a drug by name and dose .

• He travelled far from home to visit the practice .

• He gave the doctor evidence of his need for medication by showing poorly focused images of discharge

ferent rates of compliance among different cohorts and that ‘ those that have done their medical degree overseas and come and get registered in Victoria sometimes don ’ t always understand that they need to register and use the system ’,” Ms Giles added .

Under SafeScript , red , amber or green messages are meant to pop up

on a prescriber or pharmacist ’ s screen

SafeScript became mandatory , AHPRA said it had taken regulatory action against 14 practitioners , although it was not clear whether this figure also included pharmacists .

Doctors and pharmacists can face criminal sanctions , with fines of up to $ 20,000 .

But without elaborating on the

‘ Only 10-30 clinicians are referred … to AHPRA per month , which is conceded to be a mere drop in the ocean .’

— Coroner Ingrid Giles

reasons why , Ms Mulligan said : “ My

harms of a deeply troubled life ?

She said : “ It cannot now be known what the long-term outcome would have been … had SafeScript been mandatory at the time he was seeking prescriptions to monitored medicines and had he not been prescribed these medicines by GPs even on a one-off or short-term basis given the complexity of the issues he faced and his access to non-prescribed medications .

“ I , therefore , cannot find definitively that [ his ] death in January 2019 was preventable .”

Not a waste of time

The department told Australian Doc-

impossible .

summaries and other correspond-

when monitored drugs are prescribed .

understanding is , due to the way the

tor that , despite the issues highlighted

And although child and youth

ence on an iPad .

An amber alert flashes when the

legislation has been drafted , we ’ re not

by the coroner , it was important to

mental health services were involved ,

It was for these reasons that Ms

drug has been prescribed by more

actually able to implement that pen-

acknowledge that SafeScript was sav-

the GP told the inquest that she had

Giles was keen to discover whether

than one doctor or dispensed at four

alty . However , legislation change is

ing lives — the subtext being that doc-

often felt she had no real backup from

real-time prescribing information fol-

or more pharmacies in the previ-

happening at the moment so that we

tors were not wasting their time in

either a psychiatrist or psychologist

lowing the boy ’ s death was now mak-

ous six months , a red alert when pre-

are able to penalise people .”

identifying a clear and unambiguous

throughout the period she had cared

ing a difference .

scribed to the patient by four or more

The coroner was far from happy .

reason to say no .

for him , stating that his ailments were

After all , it has been a long , frus-

doctors in the past 90 days .

“ While prescribers and dispens-

But it said the Victorian Govern-

beyond her scope of practice as a GP .

trating road , with numerous coroners

Ms Giles said the department ’ s

ers bear the obligation to check Safe-

ment was undertaking legislative

When it came to his GP care , she

over the past 20 years expressing their

current approach was to send out for-

Script as a matter of law ,” she wrote

reform to “ strengthen compliance and

said she had repeatedly stressed to

exasperation at the failure of both

mal letters to doctors who were found

in her conclusions , “ the fact that only

enforcement measures ”.

him the need to see her and her alone .

state and federal governments to cre-

not to be checking SafeScript when

10-30 clinicians are referred by the

It provided no further detail except

But he obviously ignored her .

ate a system to support doctors trying

required .

[ Victorian ] Department of Health

to say it would allow for more “ timely

In the year before his death , he vis-

to protect patients .

The department said , on average , it

to AHPRA per month , which is con-

and proportionate regulatory inter-

ited 70 different GPs in his attempt to

But she was told that engagement

sent out these letters in relation to an

ceded to be a mere drop in the ocean

vention , making tools like SafeScript

source drugs .

with the SafeScript system in Victoria

average of 830 patients each year .

of the ‘ many , many thousands ’ of

more efficient and more effective ”.