Coronial
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Finding into death of Milica (Mary) Minchev

Deceased

Milica (Mary) Minchev

Demographics

48y, female

Coroner

Coroner Audrey Jamieson

Date of death

2013-02-26

Finding date

2016-10-07

Cause of death

Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazepam, alprazolam, temazepam) and amitriptyline

AI-generated summary

A 48-year-old woman with epilepsy, depression, anxiety and documented drug dependence died from combined toxicity of oxycodone, benzodiazepines, amitriptyline and other drugs. Over 12 months pre-death, she obtained medications from 31 doctors across 12 medical services, with extensive prescription shopping. Key clinical failures included: failure to coordinate care despite known prescription shopping; continued prescribing of drugs of dependence without proper DPR notifications; failure to obtain required Schedule 8 permits; inadequate medical record-keeping providing no clinical rationale for prescribing; combination of high-dose opioids and benzodiazepines without documented risk assessment; and doctors assuming other practitioners were managing her care. Contributing system factors included lack of real-time prescription monitoring and variable understanding of obligations under Victorian drugs regulation.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepsychiatryneurologypain medicinepathologytoxicology

Error types

diagnosticmedicationcommunicationsystemdelay

Drugs involved

oxycodonediazepamalprazolamtemazepamamitriptylinenordiazepamnortriptylinecodeinemorphinegabapentinlamotrigine

Clinical conditions

epilepsydepressionanxietysubstance abuse disorderbenzodiazepine dependenceopioid dependencechronic painborderline personality disorderhistrionic personality traitsdependent personality traitsmild strokemyocarditisbiventricular dilatation

Contributing factors

  • Extensive prescription shopping from 31 doctors across 12 medical services
  • Failure to coordinate care despite documented knowledge of prescription shopping at multiple clinics
  • Continued prescribing of drugs of dependence to a known drug-dependent patient without proper DPR notifications
  • Failure to obtain required Schedule 8 permits for oxycodone prescribing
  • High-dose opioid and benzodiazepine combination prescribing without documented risk assessment
  • Inadequate medical record-keeping with no documentation of clinical rationale for prescribing
  • Doctors assuming other practitioners were managing the patient's care
  • Synergistic cardiorespiratory depression from oxycodone, benzodiazepines and amitriptyline
  • Absence of real-time prescription monitoring system in Victoria
  • Variable awareness of legal obligations under drugs regulation

Coroner's recommendations

  1. Distribution of this finding to doctors who provided statements to assist identification of clinically sub-optimal practices in managing drug-dependent patients
  2. Emphasis on requirement that all practitioners must perform independent clinical assessment before prescribing, regardless of whether patient has another principal treating doctor
  3. Implementation of real-time prescription monitoring (RTPM) system in Victoria to limit prescription shopping and provide doctors with better oversight of patients' medication access
  4. Comprehensive review and streamlining of Schedule 8 permit arrangements as part of RTPM implementation
  5. Enhanced education for general practitioners regarding: obligations under drugs and poisons regulation; requirement to notify DPR when prescribing drugs of dependence to drug-dependent patients; risks of combined opioid and benzodiazepine prescribing; management strategies for drug-dependent patients including coordination of care and single pharmacy arrangements
  6. Improvement of medical record-keeping standards to include documentation of clinical rationale for prescribing decisions, particularly regarding drugs of dependence
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

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