Ms Johnstone, who was taking a range of medications as a result of an ongoing battle with post-traumatic stress disorder, underwent facial surgery at a Canberra clinic on January 5, 2015.

She was discharged the following day and prescribed with endone for pain. She was also prescribed her regular medications which included imovane, valdoxan, tramadol and valium.

Her doctors did not know Ms Johnstone was also taking an over-the-counter sleeping medication containing doxylamine and codeine.

While the prescribing doctor did try to contact Ms Johnstone's regular GP to consult on what drugs she was using, the system fell down because that person was on vacation.

Ms Johnstone was not warned of any significant risks associated with taking a cocktail of pain relief and other medications. She was warned about the risk of drowsiness.

Her daughter, Ariarne Bunyan, came home from work on January 7 to discover her mother's dead body.

There are similarities between Ms Johnstone's tragic passing and the death of Paul Fennessy in Canberra in 2010.

Margaret Hunter, the coroner who conducted the inquest into Mr Fennessy's death in 2017, recommended the establishment of a prescription monitoring program in the hope similar tragedies could be averted in the future.

Despite calls by Mr Fennesy's mother, Ann Finlay, for the program to be extended to pharmaceutical drugs that had been linked to multi-drug toxicity, and for it to be mandatory for all doctors and pharmacists, the ACT government opted for a voluntary scheme that excluded most benzodiazepines.

Ms Finlay, who wanted the ACT to have the best possible system from the get go, told the then Health Minister, Meegan Fitzharris: "doctors are highly skilled professionals, but the statistics are telling us they get it wrong given the rate of accidental drug-related deaths... now exceeds [motor vehicle accident] related fatalities across Australia... surely doctors would welcome a system that provides them with real time medication information to decrease the risk of prescription shopping and harm to their patients".

That said, DORA was still a significant step up from the previous scheme under which pharmacists filed weekly reports with ACT Health on what prescriptions had been filled.

ACT Chief Coroner, Lorraine Walker, conducted the inquest into Ms Johnstone's death. She found it was the result of an accidental overdose that resulted from her taking her normal prescription medications in conjunction with an over-the-counter medication her doctors had not known about.

The coroner recommended significant changes to DORA, which has only been in operation for the past four months. These included declaring tramadol, doxylamine and diazepam to be monitored drugs and including all schedule three and schedule four drugs or, alternatively, certain prescription and over the counter medications that may have significant sedating effects when taken with opioids or benzodiazepines.

She also wants clinics to make sure pre-admission forms list all the over the counter medications patients are taking.

All of these recommendations are eminently sensible and should be adopted at the earliest opportunity given the clear and present danger these substances represent to many people in our community.