Inquest into the Death of Daniel James HALL

Inquest into the Death of Daniel James HALL

Delivered on :10 February 2016

Delivered at : Perth

Finding of : Deputy State Coroner

Recommendations :Yes

Secure Database

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.  The intention is to ensure those with drug seeking behaviour understand prescribers must comply with regulation to enable a prescription to be written.


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.  How that is achieved is up to the regulator.  Again the concern is not with policing but providing prescribers with a mechanism with which to decline to prescribe in the face of undue pressure from drug seekers. 


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.  This is to include reportable Schedule 4 poisons and amounts with intended reduction regime, if that is applicable.

Australia Wide Dispensing Information

12. The ultimate aim for the secure regulated database held by the WA Government regulator be for all prescription medicines to be captured.  If medication warrants a prescription, it warrants monitoring.

13. The ultimate aim for real time ERCCD data should be for Australia wide access to dispensing data for medical practitioners, registered pharmacists and authorised suppliers.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Both Schedule 4 and Schedule 8 drugs can be prescribed using Pharmaceutical Benefits Scheme (PBS) prescriptions or non PBS (private) prescriptions (no PBS benefit).  Only PBS prescriptions are monitored by the Commonwealth via Medicare.  WA Health collates information on both PBS and off PBS medication. 

The death of the deceased was examined at inquest along with two others, Adrian Marcus Westlund and Shane Andrew Berry, where previously registered drug addicts obtained drugs which contributed to their death, despite the controls imposed by legislation.  The three cases are quite different, but all demonstrate the difficulties facing prescribers in attempting to treat patients sympathetically, without the ability to verify information in real time, and still maintain a relationship with their patient which allows them to prescribe in the patient’s best interest. 

While the deceased in this case was not a registered drug addict at the time he obtained multiple scripts for benzodiazepines, real time dispensing information with respect to benzodiazepines would have identified his drug seeking behaviour.

In all three cases the Commonwealth Prescription Shopping Information and Alert Service advice line (doctor shopping hotline) would not have assisted an enquiring medical practitioner despite it being a “real time” monitoring tool due to the fact none of the deceased fulfilled the statutory criteria for “doctor shopping” status, although clearly demonstrating drug seeking behaviour.

This case related to issues around prescribing for CPOP registration and enquiry of either the Commonwealth or State would not have taken the matter further for the prescriber than did his discussion with the Next Step doctor over the application for registration.  In this case the issue was more to do with benzodiazepine prescribing than Schedule 8 medicines.

The drugs in question were Schedule 8 (opioids) and Schedule 4 (benzodiazepines) and the issue of tolerance in individuals being a relevant factor.

The deceased was a 26 year old male who had developed benzodiazepine and opiate dependences.  The deceased became a registered drug addict on the 23 December 2009.  In May 2010 all the doctors routinely involved with the deceased and his medical problems were made aware of his drug addict status. 

The Coroner found the deceased died on 31 July 2010 after he had ingested a number of OxyContin tablets prescribed to him as analgesics following a day surgery procedure on his nose, contrary to the prescriber’s instructions.  OxyContin is the slow release form of the Schedule 8 opioid, oxycodone, of the Western Australian Poisons Act 1964, which incorporates the standard for the Uniform Scheduling of Medicines and Poisons (SUSMP) utilised by the Commonwealth Therapeutic Goods Administration (TGA) to promote standardised scheduling, packaging and labelling for a variety of medicines available across Australia.

The Coroner found the post mortem examination of the deceased revealed his death had been caused by a lethal quantity of oxycodone.  Levels which were considerably in excess of the deceased’s compliance with his prescription.

The Coroner was satisfed the deceased took a minimum of 10 oxycodone tablets in the 24 hours preceding his death and died as a result of that overdose, exacerbated possibly by bronchopneumonia and the sedating effect of other drugs located in his system, which on their own would have been safe. 

The Coroner did not find the deceased had any intention of dying and his death was as a result of his inability to control his desire for the effects of an opiate overdose.

The Coroner found death arose by way of Misadventure.

Catch Words : Schedule 8 poisons : Schedule 4 poisons : Dependency Register : CPOP programs : Doctor Shopping : Opioids : Benzodiazepines : Misadventure.

Last updated: 30-Apr-2019

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