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VIChospital2014-05-20

Finding into death of Jonathan Mark Smith

55y · Male·recurrent aspiration pneumonia in a man with severe intellectual disability comp…

Jonathan Smith, a 55-year-old man with severe intellectual disability due to childhood encephalitis, died from recurrent aspiration pneumonia. He had experienced three episodes within a year prior to death. After admissi…

geriatric medicinerespiratory medicineclindamycin
VIC2014-05-08

Finding into death of Gregory John Caulfield

34y · Male·Multiple injuries sustained in a fall from a height

Gregory Caulfield, aged 34, died from multiple injuries sustained falling from a ninth-floor balcony while attempting to escape police attempting to arrest him for burglary. During the arrest attempt in a confined flat, …

forensic medicineemergency medicinecommunicationproceduralamphetamine
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death re…

psychiatryemergency medicinecommunicationsystemdiazepam
VICaged care2014-04-29

Finding into death of Marie Goder

84y · Female·Major cerebral infarct due to hypoglycaemia

Marie Goder, an 84-year-old with diabetes, developed severe hypoglycaemia following insulin administration at a nursing home on 1 November 2009, resulting in prolonged unconsciousness and bilateral cerebral infarcts. Aft…

general practicegeneral medicinediagnosticmedicationactrapid
VICcommunity2014-04-24

Finding into death of Mark Bethell

32y · Male·Valproic Acid Overdose

Mark Bethell, a 32-year-old with bipolar affective disorder and borderline personality disorder, died from valproic acid overdose at a crisis accommodation facility. He was admitted to John Cade Psychiatric Unit followin…

psychiatryemergency medicinediagnosticcommunicationsodium valproate
VICcommunity2014-03-19

Finding into death of Darren Brett Kingma

29y · Male·Bronchopneumonia complicating neck injuries sustained in a fall, with Coffin-Low…

A 29-year-old man with Coffin-Lowry Syndrome suffered a severe cervical spinal cord injury from a fall at a respite facility. Disability workers found him on the floor but initially interpreted his presentation as non-co…

emergency medicineradiologydiagnosticcommunicationclonazepam
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
WAmental health- 11 April 2014

Inquest into the Death of Antoinette WILLIAMS

19y · Female·combined drug effect and myocarditis

A 19-year-old Aboriginal woman with alcohol and cannabis abuse died at Graylands Hospital from combined drug effect and myocarditis. Following two suicide attempts within 48 hours, she was sedated and transferred via Roy…

psychiatryemergency medicinemedicationcommunicationhaloperidol
WAhospital2013-09-05

Inquest into the Death of Fisher, Hayley Bree

27y · Female·opiate toxicity (fentanyl)

Hayley Fisher, a 27-year-old midwife at King Edward Memorial Hospital, died from accidental opiate toxicity after injecting a fatal quantity of fentanyl she obtained from a patient-controlled analgesia device. She had a …

obstetricsanaesthesiasystemfentanyl
SAhospital2013-09-04

Coroner's Finding: THALBOURNE-MAITREYA Michael Anthony

55y · Male·toxic effects of quetiapine and clonazepam

A 55-year-old man with bipolar affective disorder died from toxic effects of quetiapine and clonazepam after intentional overdose. He was found unconscious at home and admitted to ICU at Royal Adelaide Hospital where he …

emergency medicineintensive carequetiapine
VICaged care2013-08-12

Finding into death of Robyn Joy Wanstall

56y · Female·Malnutrition arising from refusal of oral intake in a setting of palliation with…

Robyn Wanstall, a 56-year-old woman with phenylketonuria, intellectual disability, Parkinson's disease, and suspected multiple myeloma with hypercalcaemia, died from malnutrition due to refusal of oral intake in a pallia…

palliative caregeriatric medicinebuprenorphine
VICaged care2012-09-10

Finding into death of Robert Edward Curry

38y · Male·End-stage respiratory failure secondary to kyphoscoliosis

Robert Edward Curry, a 38-year-old man with profound intellectual disability, cerebral palsy, severe kyphoscoliosis, and chronic respiratory compromise died from end-stage respiratory failure. A medication administration…

general practiceforensic medicinemedicationcarbamazepine
VIChome2012-05-18

Finding into death of David Andrew Trengrove

38y · Male·Toxic effects of morphine in a setting of benzodiazepine dependency

A 38-year-old man with chronic pain, mental illness, and benzodiazepine dependency died from morphine toxicity. He obtained multiple benzodiazepines and opioids from five different doctors through 'prescription shopping'…

general practicepsychiatrymedicationcommunicationmorphine
VICmental health2012-03-23

Finding into death of Adrian Martin Young

39y · Male·Compression of the neck consequent upon hanging

Adrian Young, a 39-year-old voluntary inpatient with severe treatment-resistant depression and chronic anxiety, died by hanging while on day leave from the Melbourne Clinic. He had been under psychiatric care since 2008 …

psychiatryforensic medicineclonazepam
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
NSWmental health2011-09-02

Ang 2011 09 21 13 31 50 906

29y · Male·acute bronchopneumonia complicated by multi-drug toxicity

Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…

psychiatrygeneral medicinemedicationcommunicationclozapine
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…

emergency medicinepsychiatrymedicationsystemclonazepam

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