Coroner's Finding: USHER Peter Michael
Deceased
Peter Michael Usher
Demographics
56y, male
Date of death
2018-11-14
Finding date
2020-10-12
Cause of death
hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose
AI-generated summary
A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 November 2018. He was found unconscious in cardiac arrest with severe hypoglycaemia. Despite paramedic resuscitation and hospital treatment including intubation, he sustained global cerebral hypoxia and died four days later. He had been placed on an Inpatient Treatment Order prior to death. The coroner found no concerns with his care or custody. Clinical lessons include the importance of mental health screening in general practice, the risks of benzodiazepine accumulation, and recognition that depression may be concealed from healthcare providers despite being known to close contacts.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- deliberate overdose of temazepam and insulin
- severe hypoglycaemia resulting in cardiac arrest
- global cerebral hypoxia from prolonged cardiac arrest
- undiagnosed or undisclosed depression
- accumulation of benzodiazepines over time
- access to mother's insulin without knowledge or control
Full text
Related cases
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —