how prescription drugs killed Nathan Attard He died a lonely death in his Redfern apartment. Nathan Attard was 34, an alcoholic, depressed, dependent on cannabis, racked with anxiety and paranoia and the subject of 52 police reports, including one for smashing an axe into his neighbour's front door. But his death in March last year was the result of a legal killer nobody saw coming - an addiction to prescription drugs. When police searched Mr Attard's apartment after finding his body, they found dozens of empty blister packs for a startling cocktail of prescription drugs including Xanax, morphine sulphate, seroquel, mirtazapine and diazepam. In the year before his death, he was seeing 22 different GPs regularly, often keeping a strict monthly regimen for one so as not to raise suspicion. All were under the assumption they were his only doctor. The widespread practice of "doctor shopping" has come under scrutiny at an inquest into the deaths of Mr Attard and three others from Sydney who were prescribed vast amounts of painkillers, sedatives and other addictive drugs. Deputy State Coroner Carmel Forbes will be urged to recommend the establishment of a statewide computerised system so doctors, pharmacists and specialists can share information and detect patients who are prescription shopping. "There can be little doubt that the problems that appear in these four cases could be avoided if a real-time prescription monitoring program [existed]," counsel assisting the coroner Kristina Stern said. Ms Stern described a litany of errors in the medical system that allowed prescription drug abusers like Mr Attard to obtain medication repeatedly for years. She outlined poor communication between doctors - sometimes within the same medical practice - and little co-ordination with other specialists, such as pain specialists and psychological experts. Doctors often failed to see signs of addiction among the four patients and those that did so did not access resources or systems available for drug dependency. The high level of risk of repeated prescription "doesn't appear to have resonated with many of the doctors who were treating them," Ms Stern said. There was a lack of documentation and no "goals" were identified, so there was no questioning of why long-term medication was having little effect on illnesses. The sheer cost was also concerning, Ms Stern said, with almost all medications paid for by Medicare. Opioid prescriptions under the Pharmaceutical Benefits Scheme ballooned from $2 million in 1992 to $7 million in 2007. The inquest heard that the number of deaths from prescription opioids more than doubled from 360 in 2007 to 705 in 2010. Patients would often say they were visiting from out of town, had damaged their prescriptions or lost medication or would outright ask for particular drugs by name, Ms Stern said. Some doctors who saw Mr Attard suspected he was "doctor shopping" and made notes expressing their concern - but they were never investigated further. One doctor called a "doctor shopping" hotline but Mr Attard was not listed. Referrals were ignored, warnings were not followed up and there were no assessments of why Mr Attard's conditions were not improving despite years of medication, the inquest heard. In a telling note, one doctor wrote in 2011: "Nathan is agitated and distressed as usual. He feels persecuted. On March 13, 2012, Mr Attard told his mother there were demons in his unit. It was the last time she spoke to her son. Police later found the apartment in a filthy state, infested with stray dogs and cats and drug paraphernalia.