Doctors ignore prescription drug watchlist SafeScript, coroner says after teenager’s fatal overdose


Giles' research into the prescribing industry found that despite mandatory requirements for pharmacists and doctors who dispense opioids and benzodiazepines to complete checks on SafeScript, a real-time monitoring platform, 30% still do not do.

“The circumstances of LI's death highlight the importance of prescribers checking SafeScript to determine whether those seeking access to prescribed medications have a genuine therapeutic need and may otherwise be at risk of impulsive drug ingestion drugs that have been prescribed, even on a one-time basis,” he said.

A compliance rate as low as 70 percent, which was the evidence provided in the investigation, is surprising since the requirement to check SafeScript is mandatory.

Coroner Ingrid Giles

“Even in 2024, some five years after the passage of LI, there is still a long way to go to achieve compliance with mandatory physician obligations.

“A compliance rate as low as 70%, which was the evidence presented in an investigation, is surprising as the obligation to check SafeScript is mandatory.”

Giles indicated that given the low compliance rates and poor enforcement of non-adherent doctors, the legislation may be inadequate to stop “doctor shopping” and prevent drug addicts from accessing dangerous pharmaceuticals.

Oxycodone is among the prescription drugs monitored by the SafeScript software. Credit: AP

“The fact that the penalty has never been administered with identified barriers to doing so, or at least to doing so easily, shows that the legislation as currently structured is lacking.”

He called the number of doctors referred to regulators, between just 10 and 30 a month, a “drop in the ocean” given the number of breaches.

Giles said it was “of great concern” that “of the many, many thousands of doctors who do not check SafeScript … only a small proportion of those referrals appear to have resulted in any action.”

Professor Edward Ogden, a specialist in addiction and forensic medicine at Swinburne University, told the inquest that SafeScript could not achieve its aims unless all professionals, including pharmacists, used the software every time.


Giles recommended that the Victorian Department of Health develop, as a matter of priority, additional strategies to improve SafeScript monitoring and compliance and expand its use.

It also recommended that the Australian Commission on Safety and Quality in Health Care consider making real-time prescription monitoring compliance a standard to be assessed under the National General Practice Accreditation Scheme .

Giles said he hoped LI's family would have some sense of closure over the circumstances of his death.

“The cause of the inquest has shown that LI was a much-loved son, grandson, nephew and friend, and his death at the age of 16 is an immeasurable and unquantifiable loss,” he said.

If you or someone you know needs help, call Kidshelpline on 1800 55 1800, Lifeline 131 114 or Beyond Blue 1300 224 636.

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