Coronial
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SAhospital2019-03-25

Coroner's Finding: NICHOLSON James

65y · Male·hypoxic ischaemic encephalopathy complicating hanging

James Nicholson, aged 65, died from hypoxic ischaemic encephalopathy following a suicide attempt by hanging while an inpatient at Noarlunga Hospital on 18 August 2015. He had undergone extensive facial cancer surgery in …

oncologypsychiatrydiagnosticcommunicationdexamethasone
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…

psychiatryemergency medicinecommunicationsystemmethadone
VIChospital2019-02-07

Finding into death of JP

39y · Male·septicaemia following self-administered intravenous injection of faeces

A 39-year-old Aboriginal man with schizophrenia, personality disorder, and substance dependence died from septicaemia after self-injecting faeces into his vein while an involuntary mental health patient. He obtained a sy…

psychiatryinfectious diseasessystemdelaypaliperidone
TAShome2019-01-21

Coroner's Finding: DS

46y · Male·Ethanol (alcohol) and prescription drug toxicity

A 46-year-old man with chronic alcohol addiction and a history of epilepsy and insomnia died from combined ethanol and prescription drug toxicity. In the three weeks before death, his alcohol consumption escalated to thr…

pathologygeneral practicealcohol
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…

psychiatryemergency medicinemedicationdiagnosticclozapine
WAhome2018-12-06

Inquest into the Death of Mark Leslie SACH

27y · Male·combined drug toxicity (U-47700 and etizolam)

Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet pu…

pain medicinegeneral practicecommunicationdelayu-47700
VIChospital2018-12-03

Finding into death of Anna Agnieszka Bowditch

34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…

Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…

orthopaedic surgeryanaesthesiaproceduraldiagnosticclonazepam
VIC2018-11-23

Finding into death of Michael Phu Tran

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, …

forensic medicinecorrectional healthcommunicationsystemmethadone
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
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

David Geoffrey Godley, aged 30, died from exsanguination due to self-inflicted multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression…

psychiatryemergency medicinedelaymethamphetamine
SAaged care2018-04-26

Coroner's Finding: MAHERAS Haralambos

74y · Male·ischaemic heart disease; acute myocardial infarction due to significant atherosc…

A 74-year-old man with severe dementia died suddenly of ischaemic heart disease while detained at a secure mental health residential facility. He had been transferred to Clements House after his severe behavioural distur…

geriatric medicinepsychiatryclonazepam
VICmental health2018-04-18

Finding into death of Gerard Helliar

62y · Male·Cerebral ischaemic injury due to hanging

Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…

psychiatryanaesthesiadiagnosticcommunicationsodium valproate
VICcommunity2018-03-14

Finding into death of C P

59y · Female·Gunshot injuries to the head

A 59-year-old woman (CP) died from gunshot injuries to the head on 19 November 2021 in West Footscray, Victoria. She was shot by her partner, Philip Bracken, following an escalating pattern of physical and emotional fami…

psychiatrydiagnosticcommunicationcitalopraam
VICcommunity2018-02-23

Finding into death of Kenneth James Stephens

51y · Male·unascertained; presumed sudden cardiac arrhythmia

Kenneth Stephens, a 51-year-old man with schizoaffective disorder, died from an unascertained cause while under involuntary psychiatric care. He presented with acute behavioural changes including excessive drinking, unus…

psychiatryemergency medicinepaliperidone
SAhospital2018-02-05

Coroner's Finding: SISSONS Anthony Vincent

38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…

Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three separate occasions (13-15 June 2012) with constipation, which was …

general practiceemergency medicinediagnosticzuclopenthixol
VIChospital2018

Finding into death of Anthony Sean Jenkins

49y · Male·Hypoxic ischaemic brain injury complicating neck compression in the circumstance…

Anthony Sean Jenkins, a 49-year-old man with significant alcohol consumption, died by hanging on 30 August 2017 after police notified him of child sexual abuse allegations made by his daughter on 23 August 2017. He was f…

intensive carepalliative caresystemalcohol
QLDhospital2017-09-07

Mr R - Non-inquest findings

63y · Male·Multiple injuries due to fall from height

A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…

neurosurgeryneurologysystemcommunicationcitalopram
VIChome2017-08-16

Finding into death of CPLH

32y · Male·Multidrug overdose

A 32-year-old man with a history of polysubstance abuse, schizoaffective disorder, and chronic pain died from multidrug overdose at home. He had obtained fentanyl, clonazepam, diazepam, methadone, and other drugs from mu…

general practiceemergency medicinesystemcommunicationfentanyl
VIChome2017-06-20

Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…

Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She en…

general practiceneurosurgerysystemcommunicationoxycodone
VIChospital2017-06-13

Finding into death of Kevin Suares

48y · Male·Complications of metastatic squamous cell carcinoma of larynx

Kevin Suares, a 48-year-old man with Fragile X syndrome and moderate intellectual disability, died from complications of metastatic squamous cell carcinoma of the larynx. He was diagnosed in March 2016 with a 12-month li…

palliative careoncologymorphine
156711

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