A coroner has criticised a Melbourne GP after the accidental drug overdose of a Tasmanian father who 'doctor shopped' to obtain prescription medication.
Brett Matthew Cashion, 48, was discovered dead by a neighbour at his home south of Hobart in September 2016.
He had overdosed on morphine and quetiapine, a coroner's report published on Monday found.
Mr Cashion suffered from chronic back pain and had for years engaged in doctor shopping, the process of consulting different professionals to get prescription drugs.
From mid-2014, he made 16 trips to Melbourne where he was prescribed morphine tablets by general practitioner Phillip Hegarty on top of his medication regime in Tasmania.
Coroner Olivia McTaggart determined Mr Cashion was responsible for his own death and was "fully aware" it wasn't proper or safe to take the morphine.
"However, at no stage over the whole treating period did Dr Hegarty take the obvious and important step of contacting Mr Cashion's treaters in Tasmania to ensure safe prescribing," she wrote.
"He would not have died at that time if he had not had access to the morphine in the days before his death."
Mr Cashion didn't tell his Tasmanian doctors he was seeing another doctor in Melbourne and was regularly being prescribed morphine.
His morphine taking became increasingly dangerous from July 2015 when he transferred to another painkiller Subutex to wean off opioids, Ms McTaggart noted.
She said Mr Cashion appeared credible to Dr Hegarty in providing a history of consultations but was clearly a "complex patient".
Dr Hegarty should have taken steps at an early stage to determine who was treating Mr Cashion in Tasmania and sought permission to contact his GP, Ms McTaggart said.
In a statement to the inquiry, Dr Hegarty said he had no reason to suspect Mr Cashion was misusing prescription drugs and did not initiate checks with any databases.
He stated he believed Mr Cashion's treating practitioners in Tasmania knew he was consulting with him.
Mr Cashion suffered from depression during his life and had expressed suicidal ideation but Ms McTaggart said there was no evidence he was suicidal at the time of his death.
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