Nine doctors missed 71 chances to save Bradley Liefvoort’s life
Despite dozens of red alerts, Bradley’s Liefvoort’s GPs failed to perform 71 mandatory checks that could have saved his life. His devastated family is now demanding change.
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A father of three will never get to see his triplets grow up because nine doctors missed more than 70 opportunities to save his life, his widow says.
Bradley Liefvoort, 46, overdosed on prescription drugs and died alone at his home in Dandenong on May 29, 2021 – just a month after his triplets first birthday.
Despite dozens of red alerts on SafeScript – a government-run system designed to limit the dispensing of high-risk prescription drugs to vulnerable users – nine doctors failed to check Brad’s profile, prescribing the new dad a lethal cocktail of pills.
His heartbroken family, including wife, Linda Matthews, are now demanding his GPs and the state government be held to account.
“The system failed Brad on such a massive level,” Ms Matthews told the Herald Sun.
“The doctors just kept supplying. If any of them had just done the right thing and checked, just said no, just tried to get him some help, put him on something else, just tried to get to the root of the problem … he was never given another option.”
“It just floored us at the time that he could continue to get this much medication.”
Victorian Coroner Audrey Jamieson, who published her findings into the Melbourne man’s death last week, said the doctors – some of whom did not hold a licence to prescribe the opioids – performed mandatory checks just six out of 77 times.
“They did not check the SafeScript System, did not heed any SafeScript system warnings,” she wrote.
“The doctors as a group instead continued to feed his dependence with ultimately fatal results.”
It has been compulsory for Victorian prescribers and dispensers to check SafeScript prior to handing over scripts for medication monitored under the system since April 1, 2020.
But Ms Matthews said Brad’s regular GP at the Ferngate Medical Centre, Dr Gregory Field – who she has since reported to the Australian Health Practitioner Regulation Agency – prescribed the pills “hand over fist”.
“He knew that Brad was addicted. He came off Endone in 2018 and then he was the one that put him back on it again,” she said
In the six months to his death, Brad was prescribed 988 tapentadol tablets and 1785 oxycodone tablets, both in excess of clinical directions.
“Because he was getting the medication from a doctor he didn’t see that in the same vein as someone who was getting something illegally off the street,” Ms Matthews said.
“I understand he made some bad choices, but when a person in a position of authority is telling you it’s OK … he trusted his doctor that it was safe.”
The devastated mum fought back tears as she said “nobody did anything to help him”.
“I’m going to have to tell my kids about how their dad was let down by the system,” she said.
“One of my boys, he’s just a spitting image of him … it breaks my heart.”
Stefan Tulloch, Medicines and Poisons Regulation Acting Director, claimed it was “not feasible” for the Department of Health to regularly engage with medical practitioners who are caring for high risk patients like Brad.
But the Coroner rejected Mr Tulloch’s claims, ruling the department “did not take appropriate action”.
“If I were to accept Mr Tulloch’s submission … then the Department of Health may never be in a position to contribute to a reduction in similar reportable deaths,” she wrote.
Ms Matthews said the Victorian government was “trying to wash their hands”.
“They’ve set the system up and now it’s up to the doctors, they say,” she said.
“That’s incredulous.”
The department told the Herald Sun “additional steps were being considered” following recommendations from the Coroner.
AHPRA confirmed they were investigating “a number of practitioners in relation to this matter”.
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