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NSW2024-10-24

Inquest into the death of Fiona Goodberg

36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…

Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…

psychiatrygeneral practicediagnosticcommunicationescitalopram
VIC2024-10-16

Finding into death of Jessica Anne Thomas

33y · Unknown·neck compression secondary to hanging

Jessica Anne Thomas, a 33-year-old gender-diverse person with complex psychiatric diagnoses including schizoaffective disorder, borderline personality disorder, and PTSD, died by hanging while remanded in custody at Dame…

psychiatryemergency medicinesystemaripiprazole
WAcommunity2024-08-13

Inquest into the Death of Amy Rebecca DEANE-JOHNS

48y · Female·Combined drug toxicity (predominantly methadone)

Amy Rebecca Deane-Johns, aged 48, died from combined drug toxicity predominantly involving methadone that she had taken without knowledge or authorization. She had a long history of mental illness with 18 inpatient admis…

psychiatrymethadone
WAmental health2024-07-19

Inquest into the Death of Phillip Benjamin VELTMAN

49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…

Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…

psychiatryemergency medicinecommunicationsystemketamine
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
VICmental health2024-04-19

Finding into death of Allison Naomi Eagle

44y · Female·Unascertained, presumed sudden cardiac death

44-year-old woman with schizophrenia and bipolar affective disorder died unexpectedly in a psychiatric inpatient unit. She had obstructive sleep apnoea and was on multiple antipsychotic medications. On the night before h…

psychiatryrespiratory medicinezuclopenthixol deconoate
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…

psychiatryemergency medicinesystemdelaysertraline
VICaged care2024-03-28

Finding into death of Joseph David Jones

76y · Male·Unascertained - natural causes

Joseph David Jones, a 76-year-old man with schizoaffective disorder, was admitted to an acute psychogeriatric unit on 29 November 2022 for a relapse associated with medication non-adherence. He was commenced on intramusc…

psychiatrygeriatric medicineolanzapine
VICcommunity2024-03-15

Finding into death of Colleen Mary South

58y · Female·Unascertained

Colleen Mary South, aged 58, was found deceased on 8 August 2022 under a tree in a remote rural paddock in Bunguluke, Victoria, approximately 1.5 kilometres from her abandoned vehicle. She had a significant psychiatric h…

psychiatryemergency medicinesystemdelayaripiprazole
VIChome2023-12-11

Finding into death of Shane Michael Tuck

38y · Male·hanging

Shane Tuck, an elite AFL player (2004-2013) and professional boxer (2015-2017), was found deceased by hanging on 20 July 2020. Post-mortem neuropathology confirmed severe stage III chronic traumatic encephalopathy (CTE).…

neurologypsychiatrycocaine
SAprison2023-11-10

Coroner's Finding: Trotta, Giovanni

58y · Male·acute bronchopneumonia

Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…

emergency medicinerespiratory medicinediagnosticcommunicationclozapine
QLDcommunity2023-10-27

SHARMA, Manmeet

29y · Male·Effects of fire

Manmeet Sharma, a 29-year-old bus driver, was killed on 28 October 2016 when Anthony O'Donohue, an untreated patient with severe psychotic illness characterised by persecutory delusions, boarded his bus and set him on fi…

psychiatrysystemcommunicationpaliperidone
VIChospital2023-10-05

Finding into death of Ruby-Lee Gold

28y · Female·Multiple injuries sustained in a fall from height

Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…

psychiatryemergency medicinesystemdelaydiazepam
VIChome2023-10-02

Finding into death of Student FSB

35y · Male·Multiple injuries sustained in a fall from a height

A 35-year-old international student from Taiwan died by suicide via fall from an 18-storey apartment building. He had prior diagnoses of anxiety disorder, psychotic disorder, and adjustment disorder documented in Taiwan …

psychiatrysystemcommunicationsertraline
VICcommunity2023-09-07

Finding into death of Angelo Anthony Gioscio

55y · Male·cardiac arrest in the setting of methylamphetamine toxicity, with possible serot…

Angelo Gioscio, aged 55, died from cardiac arrest in the setting of methylamphetamine toxicity with possible serotonin syndrome, complicated by pre-existing cardiac and respiratory disease, whilst in police presence. He …

forensic medicinetoxicologymethamphetamine
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…

psychiatrygeneral practicediagnosticsystembuvidal
NSWhome2023-07-05

Inquest into the death of JY

5y · Male·multiple stab wounds

A 5-year-old boy died from multiple stab wounds inflicted by his father during an acute psychotic episode. The father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deteri…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
VIChome2023

Finding into death of Mr ZJF

27y · Male·Dextromethorphan toxicity

Mr ZJF, a 27-year-old man with a longstanding history of schizophrenia, polysubstance use disorder, and depression, died from dextromethorphan toxicity. He was subject to a Community Treatment Order at the time of death …

psychiatrygeneral practicesystemdextromethorphan
WAcommunity2022-12-12

Inquest into the Death of Lewis Henry Mark WESTON

22y · Male·ligature compression of the neck (hanging)

Lewis Weston, aged 22, died by suicide on 3 November 2020 while subject to a Community Treatment Order (CTO) for Schizoaffective Disorder. He presented with first-episode psychosis in 2017 and repeatedly refused antipsyc…

psychiatryemergency medicineolanzapine

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