124 results
22y · Male·acute blood loss from incised injuries to left forearm
Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…
54y · Male·incised wound to the neck
Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…
29y · Male·neck compression due to hanging
Nicholas Edward Bell, aged 29, died by hanging in Mobilong Prison on 29 April 2015. He had a documented history of mental illness, previous suicide attempts, substance abuse (methamphetamine, heroin, alcohol), and was as…
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
Maris Kugis, a 68-year-old man with chronic schizophrenia, personality disorders, and multiple serious physical conditions including COPD, ankylosing spondylitis, and undiagnosed pancreatic adenocarcinoma, died from bron…
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…
Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…
30y · Male·Ischaemic heart disease and coronary artery atherosclerosis
A 30-year-old male prisoner died of ischaemic heart disease with coronary artery atherosclerosis. He had a history of cannabis and methamphetamine use, anxiety, and asthma. While in custody, he was prescribed methadone, …
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…
38y · Female·Complications of decompensated liver failure due to cirrhosis secondary to Hepat…
Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to re…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…
41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…
A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…
76y · Female·Acute renal failure due to dehydration due to upper gastrointestinal bleed
A 76-year-old woman with chronic pain was admitted to a small rural hospital on 1 April 2015 with haematemesis secondary to NSAID use. Blood tests were ordered on admission but not transported to the district hospital fo…
59y · Male·Unascertained
Louis Naumovski, a 59-year-old man with a long history of substance use disorder, chronic pain, depression, and multiple suicide attempts, was found deceased at his home after approximately three weeks. The exact date an…
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…
45y · Male·undetermined in a man in correctional services custody with a chronic history of…
Leister John Ross, a 45-year-old Aboriginal prisoner, died in Port Phillip Prison on 10 July 2014 from an undetermined cause in a man with chronic illicit drug use. Forensic pathology revealed pulmonary oedema, hepatic c…
84y · Male·Complications of gout and old spinal injury, cause unknown
An 84-year-old male prisoner with multiple comorbidities (gout, spinal cord injury, renal impairment, cardiac failure) presented with chest infection, abdominal pain, and urinary retention. He was treated with intravenou…
33y · Male·Mixed drug toxicity (heroin, buprenorphine and benzodiazepines)
A 33-year-old man with polysubstance abuse disorder and mental illness died from mixed drug toxicity (heroin, buprenorphine, and benzodiazepines). He engaged in 'prescription shopping' across multiple medical practices, …
22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…
Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…
26y · Male·Multiple drug toxicity and bronchopneumonia
Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.