Coronial
Filters:
VICmental health2015-07-03

Finding into death of Anthony Travaglini

40y · Male·combined drug toxicity in a man with asthma (undiagnosed) and sleep apnoea

Anthony Travaglini, a 40-year-old with schizoaffective disorder, severe sleep apnoea, and undiagnosed asthma, died from combined drug toxicity on a psychiatric high-dependency unit. Critically, his earlier clinical recor…

psychiatryrespiratory medicinesystemcommunicationzuclopenthixol
VICmental health2015-05-27

Finding into death of Waldemar Ariel Ogon

45y · Male·spontaneous lethal arrhythmia arising from focal myocardial fibrosis

45-year-old man with bipolar disorder admitted to psychiatric unit involuntarily died from spontaneous lethal arrhythmia due to focal myocardial fibrosis. Critical issue was inadequate visual observations overnight—the p…

psychiatryforensic medicinecommunicationsystemolanzapine
VICcommunity2014-08-25

Finding into death of Travis Joseph Hartskeerl

32y · Male·Head and neck trauma (train impact)

Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…

psychiatrygeneral practicecommunicationsystemzuclopenthixol decanoate
VIChome2014-03-06

Finding into death of Melanie Jane Maher

36y · Female·Effects of fire (schizophrenic psychotic episode); for children: effects of fire…

This case involved the deaths of Kylie Fowler (36) and her three children—Samantha (18), Melanie (13), and Matthew (11)—in a house fire on 9 January 2011. Kylie, with an 18-year history of schizophrenia requiring five in…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Kylie Jane Fowler

36y · Female·Effects of Fire

A 36-year-old woman with a 18-year history of schizophrenia killed herself and her three children (ages 11, 13, and 18) in a house fire with stab wounds on 9 January 2011. Ms Fowler had five involuntary psychiatric admis…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Matthew Patrick James Maher

36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …

Kylie Fowler, a 36-year-old woman with a 18-year history of schizophrenia requiring five involuntary psychiatric admissions, killed herself and her three children (Melanie, 13; Matthew, 11; Samantha, 18) on 9 January 201…

psychiatrypaediatricscommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Samantha Jane Fowler

36y · Female·Effects of fire and stab wounds (Kylie Fowler); effects of fire (Melanie Maher);…

Kylie Fowler, a 36-year-old woman with severe schizophrenia and a 18-year history of involuntary psychiatric admissions, killed her three children (Samantha 18, Melanie 13, Matthew 11) and herself by stabbing and fire on…

psychiatrypaediatricscommunicationsystemrisperidone
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Clinical…

psychiatryintensive caresystemcommunicationrisperidone
VIChospital2012-01-23

Finding into death of Elizabeth Maryanne Holley

52y · Female·Hypoxic brain injury due to hypotension in a woman with documented electrocardio…

Elizabeth Holley, 52 years old, was admitted involuntarily to a psychiatric ward with a history of three weeks of declining mental health and medication non-compliance. She received high-dose antipsychotic medications in…

psychiatryintensive careolanzapine
VICmental health2011-07-22

Finding into death of Lionel Raymond Perry

44y · Male·Cardiomegaly

Lionel Perry, a 44-year-old Aboriginal man with schizoaffective disorder and polysubstance abuse history, died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric…

psychiatryemergency medicinecommunicationdocumentationmethadone
VICmental health2011-04-20

Finding into death of Nigel Delaney

51y · Male·unascertained

Nigel Delaney, aged 51, died of unascertained cause while admitted to an acute psychiatry inpatient unit following relapse of schizoaffective disorder. He was found unresponsive during night observations and could not be…

psychiatryforensic medicineolanzapine
VICaged care2010-03-30

Finding into death of Mark Anthony Theakston

45y · Male·unascertained

Mark Anthony Theakston, a 45-year-old man with severe intellectual disability and autism residing in supported accommodation, died of an unascertained cause on 25 May 2008. He had collapsed on 21 May with a syncopal epis…

general practiceforensic medicinesystemcommunicationchlorpromazine
SAcommunity2009-12-16

Coroner's Finding: PENN Dulcie Janet Mary

83y · Female·Congestive cardiac failure due to ischaemic and valvular heart disease

An 83-year-old woman with Down syndrome and cardiac disease died from congestive cardiac failure at Royal Adelaide Hospital following accidental medication administration error in a community group home. On 1 July 2007, …

emergency medicineintensive caremedicationproceduralclozapine
QLDaged care2009-10-01

Streader, Leon

68y · Male·coronary atherosclerosis worsened by heat stroke

Leon Streader, a 68-year-old man with schizophrenia, epilepsy, obesity, and coronary artery disease, died from coronary atherosclerosis worsened by heat stroke whilst residing in a level-3 accredited hostel on an extreme…

general practicepsychiatrysystemdelaybenztropine
WAhospital2009-08-13

Inquest into the Death of Greeuw

45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction

Vicki Margaret Greeuw, a 45-year-old woman with schizoaffective disorder, died on 13 May 2007 at Albany Regional Hospital from aspiration of vomitus secondary to bowel obstruction due to severe faecal impaction. She had …

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
SAhospital2007-06-29

Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…

psychiatryemergency medicinemedicationcommunicationhaloperidol
WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…

general practicepsychiatrythioridazine
SAmental health2000-06-16

Coroner's Finding: FERN Edmund James

30y · Male·cardiac arrhythmia due to therapeutic clozapine use

Edmund James Fern, aged 30, died at a psychiatric institution (James Nash House) on 4 September 1997, nine days after septoplasty for nasal obstruction. He was on multiple medications including clozapine 350mg nightly, c…

psychiatryENT surgerymedicationsystemclozapine
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …

psychiatryneurologyescitalopram

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