Coronial
NSWother

Inquest into the death of TH

Deceased

TH

Demographics

57y, male

Date of death

2022-05-26

Finding date

2023-12-12

Cause of death

Chronic Coronary Artery Atherosclerosis in the context of mirtazapine toxicity

AI-generated summary

A 57-year-old male prisoner died of chronic coronary artery atherosclerosis in the context of mirtazapine toxicity. He had been incarcerated for over 40 years following conviction for two murders committed at age 16. The deceased was frustrated with ongoing parole denials despite completing required courses, believing there was a conspiracy to keep him imprisoned. He made statements indicating suicidal intent, including telling a psychologist he would 'carry out their death sentence' if not granted parole in 2022. He obtained unprescribed medications (mirtazapine and paracetamol at toxic levels) and deliberately overdosed in his cell. While he had significant cardiac risk factors, the intentional ingestion of medications and documented suicidal statements confirm this was a self-inflicted death. No clinical or procedural errors were identified.

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

Contributing factors

  • Severe chronic coronary artery atherosclerosis
  • Mildly enlarged heart
  • Paracetamol toxicity
  • Suicidal intent related to parole denial
  • Psychological distress from repeated parole refusal
  • Unauthorised access to medications
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