The death of an elderly Melbourne man from chemotherapy drug toxicity was "entirely preventable", a coroner has found.
Ian John Gilbert, 77, died in February 2015 after being prescribed methotrexate for a skin condition, following "extreme concerns" expressed by the dispensing pharmacist about the daily dose prescribed by the patient's GP.
However, Dr Stephen Lim assured the pharmacist he had checked the dose and it was correct.
"(Mr Gilbert's) death from complications of methotrexate toxicity was needless and entirely preventable," Coroner Rosemary Carlin said in her findings on Thursday.
"If appropriate tests had been conducted by his GP, they would have shown that his pre-existing medical conditions contraindicated the use of methotrexate at all, let alone at the dose prescribed.
"The fact that the drug was intended to treat a non-life threatening skin condition makes his death all the more tragic and the decisions to prescribe and dispense all the more inexplicable."
The coroner made recommendations including that the federal government look into making methotrexate an "authority required medication".
"It would certainly promote reflection about the risks of the drug and prevent ad hoc and spontaneous prescribing, as occurred in this case," she said.