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Finding into death of Kim Michelle Cooper

Deceased

Kim Michelle Cooper

Demographics

47y, female

Coroner

Coroner David Ryan

Date of death

2020-05-27

Finding date

2022-08-08

Cause of death

Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)

AI-generated summary

A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death, she was prescribed escalating doses of oxycodone by two different doctors without SafeScript checks or Schedule 8 permits as legally required. She also accumulated excessive pregabalin from multiple clinicians across three months. Key clinical lessons: mandatory SafeScript checking for opioids must be performed before every prescription; oxycodone requires Schedule 8 permits; doctors must coordinate care when patients see multiple prescribers; pregabalin combined with benzodiazepines and opioids carries serious CNS depression risks. The coroner found this death was a missed opportunity—SafeScript compliance could have prevented it.

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

Specialties

general practiceaddiction medicinepsychiatrypain medicine

Error types

medicationsystemcommunicationdelay

Drugs involved

pregabalinoxycodonemirtazapinebenzodiazepinesdiazepamoxazepamzolpidemtemazepamcodeinecannabis

Clinical conditions

chronic paindepressionanxietyopioid use disordersubstance use disordersuspected cervical spine malignancyC7 vertebral damageopioid toxicitymixed drug overdose

Contributing factors

  • Failure to check SafeScript before prescribing oxycodone
  • Failure to apply for Schedule 8 permit for oxycodone prescribing
  • Multiple prescribers issuing high-dose medications without coordination
  • Escalating oxycodone doses issued in five days by different doctors
  • Excessive pregabalin dispensed (1587mg daily vs 450-900mg directed)
  • Combination of CNS depressant drugs with synergistic effects
  • History of prescription medication misuse not adequately managed
  • Patient did not attend referral to addiction medicine specialist
  • Inadequate monitoring of medication accumulation across multiple providers

Coroner's recommendations

  1. Checking SafeScript provides doctors and pharmacists with accurate prescribing information for targeted drugs to inform safe treatment decisions and improve clinical practice
  2. Pregabalin should be included in drugs monitored by SafeScript system given evidence of abuse and potential for harm in combination with other CNS depressants
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