Finding into death of Milica (Mary) Minchev

48y · Female·Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazepam, alprazolam, temazepam) and amitriptyline

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.