Inquest queries co-prescribing

legal medical tribunal doctor overprescribing

A GP has been cleared of inappropriate treatment after a combination of prescription and non-prescription drugs contributed to a patient’s death

Combined toxicity of prescription and non-prescription drugs contributed to a 52-year-old ACT man’s death, however his prescribing GP was not at fault, an inquest has found.

The man, who had several conditions including bipolar disorder, neuropathic pain, Hepatitis B and C and chronic airways disease, died in December 2016 from septicaemia caused by pneumonia.

Suffering from an undiagnosed illness and urged to go to the hospital, the deceased was observed to have injected himself in his home shortly before death, with a substance suspected to be heroin.

Post mortem toxicology showed the presence of multiple substances including codeine, tetrahydrocannabinol, diazepam, morphine, 6-monoacetylmorphine, oxazepam and temazepam.

Toxicological testing was unable to identify whether the morphine and codeine that was detected was consumed separately or just a breakdown product of heroin use.

Lithium and alcohol were not reported as detected, although the patient had been prescribed the former and was known to be a heavy user of the latter.

In a recent inquest, Chief Coroner Lorraine Walker directed that a review of the man’s medical records be undertaken to consider the appropriateness of the medications he was prescribed.

An expert witness who conducted the medical review queried the patient’s co-prescription of oxazepam and diazepam.

She also noted that one way to mitigate the risk of benzodiazepine medication being misused is to ask the patient to voluntarily sign a ‘benzodiazepine contract’—where the patient makes undertakings to not attend upon other doctors and only attend a single pharmacy for dispensing of prescriptions.

The witness queried why there was no such contract in place.

The GP told the inquest that she prescribed the patient diazepam for anxiety during the day, and oxazepam at night for insomnia, feeling that these medications were appropriate for his presentation – despite being outside the regular guidelines – and kept his symptoms to a manageable level.

She also explained that the patient had not been prepared to enter into a ‘benzodiazepine contract’, however he assured her he was only receiving prescriptions from herself.

Her usual practice was to prescribe enough medication for one month, and require the patient to attend upon her monthly to receive new scripts.

She added that she was reluctant to wean the patient off benzodiazepines because he was a long-term user at risk of withdrawal seizures, and this also risked him resorting to less desirable means of self-medication.

Acting Chief Coroner Glenn Theakston found that based on the GP’s explanation for co-prescribing oxazepam and diazepam, “this was not an unreasonable prescription in the circumstances” given the deceased was a long-term regular patient.

He made no adverse comment or finding against the GP in respect to her treatment of the patient.

“It appears she did the best she could with a complex patient,” said the acting coroner in findings handed down this month.

“I agree it is likely that [her patient] would have self-medicated with other substances had [the GP] refused or tightened the conditions of treatment.”

He said that at the last consultation, the doctor had appropriately referred the patient to hospital in respect of his deteriorating health.

Previous Pharmacists on the front line
Next Research Roundup

NOTICE: It can sometimes take awhile for comment submissions to go through, please be patient.


  1. Kevin Hayward

    We had a similar patient recently. I provided a medicines review and some patient education. Sat in with patient and GP to provide counselling re meds. Participated in a case conference with the team, where Pharmacist input provided was relevant in developing a plan of care. Good audit trail available, relevant where an inquiry takes place. A great example of how practice support Pharmacist can be of value.

  2. chris

    Another one bites the dust

  3. Notachemist

    While due scrutiny is important in these situations most health care professionals are doing the best they can and are not to blame when people make poor decisions about mixing medication and illicit substances. Real time monitoring will not pick up use of illicit drugs.

Leave a reply