Linda Matthews describes her late husband Brad Liefvoort as a joker, the kind of person who "could talk the leg off a chair".
The 46-year-old was a technology enthusiast, a Melbourne Storm fan and desperately wanted to be a loving and engaged father to his young triplets.
But Mr Liefvoort's addiction to prescription painkillers took an increasing toll on his life, leading to the breakdown of his marriage and eventually causing his death.
After days of unanswered calls and messages, police entered Mr Liefvoort's unit on June 1, 2021 to perform a welfare check.
They found him dead, still clutching prescription medication in his hand.
A pathologist later deemed he had overdosed from the opioid painkillers tapentadol and oxycodone.
Alerts on 'doctor shopping' database
A Victorian coroner has now ruled there was a link between the fatal drugs Mr Liefvoort consumed over a lengthy period, and nine Melbourne GPs who filled out prescriptions without checking a government database designed to prevent "doctor shopping".
In the six months leading up to his death, the coroner found Mr Liefvoort was prescribed 988 tapentadol tablets, 1,785 oxycodone tablets and 556 diazepam tablets.
Coroner Audrey Jamieson found that on 71 occasions doctors failed in their legal obligations to check the SafeScript database before issuing packets of highly addictive drugs to Mr Liefvoort.
Had the GPs looked up his record on SafeScript, they would have seen a series of amber and red alerts.
Some doctors also failed to secure permits to prescribe the medications, which were categorised as Schedule 8 poisons.
'Masses and masses of medication'
Ms Matthews said her husband's dependence on strong painkillers worsened from debilitating stomach conditions and a rare autoimmune disorder.
She thought her husband was seeing two GPs but was "gobsmacked" to later learn he was regularly getting medication from several others and obtained 77 prescriptions in six months.
"Sometimes every four days he was fronting up to a doctor and getting masses and masses of medication. There are systems in place to stop this happening, and the systems were ignored by the doctors involved," she said.
"He can't have stumbled on the only nine doctors in Victoria who are doing the wrong thing."
With the support of her extended family, Ms Matthews is now raising the couple's three children, who are too young to understand what happened to their father.
"At the end of the day, they don't have a dad and this could have been avoided," Ms Matthews said.
Ms Matthews is calling for the doctors involved to be struck off the register, but more importantly, wants better education for GPs and changes to be made to ensure similar tragedies don't occur again.
Doctors investigated for use of SafeScript, AHPRA confirms
In written findings, Coroner Jamieson said there was "a causal nexus" between Mr Liefvoort's death and the actions of several doctors.
"…the conduct of Bradley Scott Liefvoort's treating medical practitioners who collectively prescribed opioid and other drugs in excess of his medical need, contributed to the chain of events leading to his death," she found.
The coroner also said the Victorian Department of Health should do more to ensure doctors were complying with their legal obligations to check SafeScript before dispensing high-risk drugs.
Since April 2020, it has been mandatory for Victorian doctors and pharmacists to check SafeScript prior to issuing strong opioid painkillers, strong medicines for anxiety, sleeping tablets and stimulants for ADHD and narcolepsy.
An alert on the system does not prevent medication from being issued, but acts as a warning for the dispenser to consider.
In 2019, SafeScript data revealed the scale of people being red-flagged for visiting multiple doctors or pharmacies seeking potentially dangerous drugs.
However, leading doctors have also complained about gaps and failings in the system.
In light of the findings in Mr Liefvoort's case, a spokesperson for the Victorian Department of Health said it would consider what additional steps could be taken to make the system safer.
The medical watchdog, the Australian Health Practitioner Regulation Agency (AHPRA) also confirmed it was investigating a number of doctors over their use of the SafeScript system.
"We are also considering whether any other regulatory action is necessary, to ensure safer practice into the future," a spokesperson said.
"We know the large majority of doctors are doing the right thing. We urge all practitioners to understand their obligations as a registered health practitioner and abide by the relevant legislation."
A coroner's report last year revealed drug overdose deaths were around double that of the annual Victorian road toll.
In 2021, pharmaceutical drugs contributed to 75 per cent of the 500 fatal overdoses, the coroner found.
