Coronial
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SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…

psychiatrygeriatric medicinehydromorphone
WAcommunity2020-10-02

Inquest into the Suspected Death of Jorn Jesper JENSEN

68y · Male·unascertained

A 68-year-old man with multiple chronic medical conditions including peripheral neuropathy, chronic pain, atrial fibrillation, dysphagia, and depression disappeared on 25 June 2017. He left home, drove his car to Lanceli…

general practicecardiologybuprenorphine
NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

Tane Chatfield, a 22-year-old Aboriginal man, died by hanging in his prison cell at Tamworth Correctional Centre on 20 September 2017. He had been admitted to hospital the preceding night with seizures, assessed as unlik…

emergency medicineneurologydiagnosticcommunicationparacetamol
VIChome2020-08-24

Finding into death of Wayne Laurence Marshall

54y · Male·Methadone use in a man with asthma and sarcoidosis of the lungs

Wayne Marshall, a 54-year-old registered nurse, died from respiratory depression caused by methadone use in the context of underlying asthma and pulmonary sarcoidosis. He was found gasping for air at home and could not b…

emergency medicineintensive caremethadone
SAhome2020-07-16

Coroner's Finding: KEIPERT Mathew James

44y · Male·Ischaemic heart disease due to coronary atherosclerosis

Mathew James Keipert, age 44, died of ischaemic heart disease due to coronary atherosclerosis while on home detention bail. He had significant cardiovascular risk factors including hypertension, heavy smoking (40 cigaret…

cardiologygeneral practicediagnosticdelaybuprenorphine
SAhospital2020-07-09

Coroner's Finding: DUNSTAN Carole Ann (Redacted)

70y · Female·end stage dementia

Carole Ann Dunstan, a 70-year-old woman with end-stage dementia, died of natural causes at Repatriation General Hospital on 17 June 2017 while subject to a Level 3 Inpatient Treatment Order. She had been admitted followi…

psychiatrygeriatric medicinerisperidone
TAShome2020-06-30

Coroner's Finding: Hinley, David John

74y · Male·Mixed prescription drug toxicity (codeine, paracetamol, mirtazapine, promethazin…

A 74-year-old man with multiple chronic conditions including cerebellar ataxia, COPD, depression and anxiety died from mixed prescription drug toxicity. He had cognitive impairment affecting medication management and hab…

general practicepsychiatrycommunicationsystemcodeine
SAhospital2020-05-21

Coroner's Finding: SOMMERVILLE Adam

73y · Male·metastatic small cell lung cancer and sepsis

A 73-year-old man with metastatic small cell lung cancer and sepsis died in Royal Adelaide Hospital while in prison custody. He had been sentenced in May 2015 and received appropriate oncology care including chemotherapy…

oncologyradiation oncologybuprenorphine
TAShome2020-05-19

Coroner's Finding: Steer, Marianne

56y · Female·combined drug toxicity (methadone, diazepam, amitriptyline and mirtazapine); pul…

Marianne Steer, 56, died from combined drug toxicity involving methadone, diazepam, amitriptyline, and mirtazapine. She had a long history of substance dependence and had voluntarily ceased methadone treatment five month…

general practiceaddiction medicinesystemmethadone
TAShome2020-05-14

Coroner's Finding: Cashion, Brett Matthew

48y · Male·combined drug intoxication from morphine and quetiapine

Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphine. He was receiving daily Subutex in Tasmania from …

general practicepain medicinecommunicationsystemmorphine
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

23y · Male·Neck compression as a result of hanging

Jonathon Hogan, a 23-year-old Aboriginal man of Wiradjuri, Ngiyampaa and Murrawarri descent, died by hanging at Junee Correctional Centre on 3 February 2018 while serving remand. He had longstanding schizophrenia with pr…

psychiatrygeneral practicediagnosticcommunicationolanzapine
VIChome2020-03-20

Finding into death of Janet Foster

55y · Female·Mixed drug toxicity in a woman with cardiomegaly and chronic obstructive airway …

Janet Foster, 55, died from mixed drug toxicity involving heroin/morphine combined with benzodiazepines in the context of cardiomegaly and chronic obstructive airway disease. She was a voluntary palliative care patient a…

emergency medicinegeneral practicecommunicationsystemmorphine
NSWaged care2020-03-03

Inquest into the death of Hazel BROCKETT

86y · Female·complications of femoral, radial and ulnar fractures; antecedent cause Alzheimer…

86-year-old Hazel Brockett died from complications of fractures inflicted by a fellow dementia-affected resident in a locked Memory Support Unit (aged care dementia facility). Over months prior, the other resident demons…

geriatric medicinegeneral practicecommunicationdiagnosticbuprenorphine
NSW2019-10-25

Inquest into the death of Ossama Al Refaay

34y · Male·acute methamphetamine toxicity from ingested balloons that burst or dissolved in…

Ossama Al Refaay, a remand inmate at Long Bay Hospital, died from acute methamphetamine toxicity after ingesting balloons containing the drug during or shortly before a prison visit. Forensic evidence indicated he had sw…

forensic medicinecorrectional healthsystemcommunicationmethamphetamine
VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

A 24-year-old man died from mixed drug toxicity after staying overnight at a backpackers hostel. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including …

psychiatrygeneral practicecommunicationsystempregabalin
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone
VIChome2019-09-26

Finding into death of Mark Richard Mennie

52y · Male·Effects of fire

A 52-year-old man with chronic substance abuse, anxiety, depression, benzodiazepine dependence and hepatitis C died in a deliberately lit house fire. He was asleep and alone in his front bedroom when the fire started on …

oxazepam
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

Two remand inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate…

psychiatrydiagnosticcommunicationquetiapine
ACT2019-06-26

Inquest into the death of Mark Anthony O’Connor

40y · Male·Multiple drug toxicity, being either an overdose due to methylamphetamine alone,…

Mark Anthony O'Connor, a 40-year-old detainee with longstanding polysubstance use disorder, died in custody from multiple drug toxicity (methylamphetamine and possibly buprenorphine) on 13 May 2017. He self-administered …

emergency medicinetoxicologymethamphetamine
WAhome2019-06-12

Inquest into the Death of Ellie Marlene HARE

25y · Female·complications of opioid toxicity

Ellie Marlene Hare, 25, died from opioid toxicity after injecting methadone on two consecutive nights with Matthew Drake. She was opioid-naïve, having not used regularly for several years. On the morning of her death, Dr…

toxicologyemergency medicinedelaymethadone

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