A 16-year-old Victorian boy, known as LI, died from a drug overdose after obtaining pain medication from 70 doctors in the year before his death.
Coroner Ingrid Giles was tasked with investigating the cause and circumstances surrounding his 2019 death during a four-day inquest in March.
He obtained 60 opioid tablets the day before he died after going to three different doctors and three different pharmacies, the court was told.
On the evening of January 28, 2019, LI died from a drug overdose in his own bed and his grandmother found his body the next morning.
In the year before his death, the teen had visited 70 different doctors and managed to obtain 64 prescriptions from 31 practitioners.
The 16-year-old was also admitted to hospital several times between 2015 and 2019 for drug issues and self-harm, including swallowing batteries and needles.
In findings released on Friday, Ms Giles said she was satisfied that while LI intended to ingest the medications, it was likely an impulsive act rather than a suicide attempt.
But she found the doctors who prescribed him with opioids, on a one-off or short-term basis, had missed an important opportunity to intervene in his "doctor-shopping" cycle.
"It was a cycle that ended in LI's death," Ms Giles said in her report.
The SafeScript system, a central database that allows a doctor to see a patient's current prescriptions, was first introduced in Victoria in October 2018 but only became more widely used in April 2019.
The coroner found if the system was as available at the time of LI's death as it is today, there could have been a different outcome for the 16-year-old.
"The GPs who saw LI would have had crucial information pointing to LI's drug-seeking behaviours, and he would likely have been refused access to certain of the highly addictive medications that he was prescribed," she said.
The coroner made a recommendation to the Australian Commission on Safety and Quality in Health Care to consider making doctors' compliance with real-time prescription monitoring a national standard.
Ms Giles also recommended Victoria's Department of Health develop additional strategies to improve its oversight and compliance role in checking SafeScript.
The coroner noted the moving statements made to the court by LI's family and friends, especially by his grandmother and father.
She acknowledged their grief and devastation, and offered her condolences.
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