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 they were breaking the law by not checking SafeScript 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 S4 and S8 drugs sourced from 14 different pharmacies scattered around his apartment and in his car.