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VIChospital2025-09-30

Finding into death of Richard Mark Ellis

64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…

Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…

emergency medicinepsychiatryamisulpride
VIC2025-09-24

Finding into death of Jay Joseph Harrison

47y · Male·Combined drug toxicity (heroin, amphetamines, hydroxyrisperidone, olanzapine)

Jay Joseph Harrison, a 47-year-old homeless man with schizophrenia and substance use disorder, died from combined drug toxicity involving heroin, amphetamines, hydroxyrisperidone, and olanzapine. He was found unconscious…

psychiatryemergency medicineheroin
NSW2025-09-03

Inquest into the death of Daniel Leehy

47y · Male·ischaemic heart disease with seizure disorder and schizophrenia being other sign…

Daniel Leehy, a 47-year-old man in custody, died from ischaemic heart disease with significant coronary artery narrowing (60-80%) identified at autopsy. He had a 42-year history of epilepsy and schizophrenia with frequen…

forensic medicinepsychiatrysodium valproate
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone
VIC2024-12-16

Finding into death of Caroline Monique Hall

52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…

Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…

general practiceemergency medicinediagnosticdelaymorphine
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
VIC2024-09-23

Finding into death of Silvio Rolfo

55y · Male·Sudden and unexpected death in epilepsy

Silvio Rolfo, a 55-year-old man with lifelong intellectual disability, autism, and longstanding infrequent epilepsy, died from sudden unexpected death in epilepsy (SUDEP) at his supported living residence. He was found o…

general practiceneurologybenztropine
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…

psychiatryspeech pathologyrisperidone
VICmental health2024-02-27

Finding into death of Sidarthan Gajaharan

26y · Male·Craniocervical injuries following a train collision (pedestrian)

Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…

psychiatryrehabilitation medicinecommunicationdelayclozapine
SAmental health2023-06-30

Coroner's Finding: Williamson, Vaughan Weston

41y · Male·undetermined

Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neuropathological …

psychiatryemergency medicineolanzapine
VIChospital2023-06-25

Finding into death of Peter John Weatherly

63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…

A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…

general medicineemergency medicinesystemcommunicationrisperidone
VICmental health2022-12-21

Finding into death of Kai Wesley Wu

23y · Male·Injuries sustained when struck by train

Kai Wu, a 23-year-old man with first-episode psychosis, died by suicide at a railway station while on escorted leave from psychiatric inpatient care. He had been admitted to The Alfred Hospital in January 2018 under Ment…

psychiatrycommunicationsystemhaloperidol
VICcommunity2022-11-23

Finding into death of Carl Robert Adler

46y · Male·Cold environmental exposure in a man with cardiomegaly

Carl Robert Adler, a 46-year-old man with treatment-resistant schizophrenia, intellectual disability, and autism, died from cold environmental exposure complicated by pre-existing cardiomegaly after leaving a community c…

psychiatrydiagnosticsystemclozapine
VICmental health2020-11-25

Finding into death of Thi Qui Tran

53y · Female·Heatstroke

Thi Qui Tran, a 53-year-old woman with schizophrenia on antipsychotic medications (zuclopenthixol and olanzapine), died of heatstroke on 9 February 2018 after collapsing on a street during extended unescorted leave from …

psychiatryintensive caresystemdelayzuclopenthixol
NSWmental health2019-10-25

Inquest into the death of T V

23y · Female·Arrhythmia of unknown aetiology

TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…

psychiatrycardiologyhaloperidol
SAhospital2019-08-30

Coroner's Finding: SHUEARD Braydon Adrian

60y · Male·Sepsis due to pressure ulcers due to immobility on a background of advancing fro…

A 60-year-old man with frontotemporal dementia, diabetes, and ischaemic heart disease died from sepsis secondary to pressure ulcers while subject to a Mental Health Act inpatient treatment order. He developed sacral and …

psychiatrygeneral medicinehaloperidol
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
VICcommunity2016-11-29

Finding into death of Phillip Richard Anderson

32y · Male·Complications of mixed drug use

A 32-year-old man with schizoaffective disorder and polysubstance abuse disorder died from complications of mixed drug use after boarding a train in an intoxicated state. He remained slumped in a train seat for nearly th…

psychiatryforensic medicinecommunicationzuclopenthixol
VIChospital2015-10-14

Finding into death of Marc Phillip Vella

39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor

Marc Vella, a 39-year-old man with schizophrenia and intravenous drug use, presented to St Vincent's Hospital with respiratory symptoms and chest pain. Clinical assessment identified pneumonia, septicaemia, and possible …

emergency medicinegeneral medicinemethamphetamine

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