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143 results

VIChome2026-04-14

Finding into death of Justin James Filardo

45y · Male·Gunshot wounds to the head and left shoulder

Justin Filardo, aged 45, with a 28-year history of schizophrenia, was fatally shot by police after assaulting his sister Bianca in her bedroom. In the weeks prior, Justin had ceased his clozapine medication without clini…

psychiatrygeneral practicesystemdelayclozapine
NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…

psychiatrycardiologycommunicationsystemclozapine
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping centre in Sydney on 13 April 2024, killing six people (Dawn Singleton, Jad…

psychiatrygeneral practicecommunicationsystemclozapine
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

On 13 April 2024, Joel Cauchi stabbed 16 people at Westfield Bondi Junction, NSW, fatally wounding six: Dawn Singleton, Jade Young, Yixuan Cheng, Ashlee Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed b…

psychiatrygeneral practicediagnosticcommunicationclozapine
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…

psychiatryaddiction medicinecommunicationsystemheroin
VICcommunity2025-11-18

Finding into death of Darren John Atkinson

50y · Male·Mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine); cardiac hype…

A 50-year-old man with treatment-resistant schizoaffective disorder died from mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine) combined with cardiac hypertrophy. He ceased his antipsychotic medication o…

psychiatryemergency medicinecommunicationsystemclozapine
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

34y · Female·not able to be determined - body not found

Sana Salman, a 34-year-old woman with bipolar disorder and schizoaffective disorder, went missing on 1 September 2022 after being discharged from Northern Beaches Hospital on 22 August 2022. She had been admitted for a p…

psychiatrysystemcommunicationclozapine
WAmental health2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with severe treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and extremely challenging violent behaviours, died at Joondalup Health Campus …

psychiatryemergency medicinesystemcommunicationclozapine
WAhospital2025-07-11

Inquest into the Death of Monique Jacinta GOMEZ

48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…

Monique Jacinta Gomez, a 48-year-old woman with schizoaffective disorder and a mechanical aortic valve, died from intracerebral haemorrhage while receiving anticoagulation therapy for a recent embolic stroke. She was adm…

neurologypsychiatrywarfarin
TAScommunity2025-06-30

Coroner's Finding: de-identified HN

42y · Male·Drowning following chest injuries sustained from jumping from the Tasman Bridge

A 42-year-old man with long-standing, well-managed paranoid schizophrenia died by suicide from the Tasman Bridge. He had been compliant with clozapine therapy for over 20 years, maintained psychiatric stability, and had …

psychiatrygeneral practiceclozapine
NSW2025-06-12

Inquest into the death of Roland Ashbolt

39y · Male·clozapine toxicity

Roland Ashbolt, a 39-year-old man remanded in custody with schizophrenia, died from clozapine toxicity. He had been prescribed clozapine (400mg daily) from January 2022 with good clinical response and therapeutic levels.…

psychiatryforensic medicineclozapine
QLDcommunity2025-05-02

Non-inquest findings into the death of Mr T.

49y · Male·undetermined

A 49-year-old man with paranoid schizophrenia on clozapine became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police atte…

psychiatrysystemcommunicationclozapine
SAcommunity2025-04-30

Coroner's Finding: Foster, Michelle Stephanie

36y · Female·head injury

A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…

psychiatryemergency medicinediagnosticcommunicationaripiprazole
VIChome2025-03-18

Finding into death of R T

66y · Male·Complications of excess alcohol intake in a man with heart disease

A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic p…

general practiceemergency medicinealcohol
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

Fiona Turnbull, a 59-year-old woman with chronic schizophrenia on clozapine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortl…

psychiatryemergency medicinedelaycommunicationclozapine
VICmental health2025-03-04

Finding into death of Jamie Alexander Knowles

24y · Male·neck compression secondary to hanging

Jamie Knowles, a 24-year-old with schizophrenia, died by suicide on 24 June 2024 while on an inpatient temporary treatment order at Kerferd Unit mental health service in Victoria. He was granted one hour of unescorted le…

psychiatrygeneral practicesystemcommunicationclozapine
VIChospital2025-02-12

Finding into death of Alexander Cameron

40y · Male·Aspiration pneumonia

Alexander Cameron, a 40-year-old man with complex neurodevelopmental, neurological and psychiatric disorders including epilepsy, autism, and previous neuroleptic malignant syndrome (NMS), died from aspiration pneumonia f…

intensive caregeneral surgeryclozapine
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …

psychiatryemergency medicinesystemclozapine
QLDcommunity2024-08-21

Inquest into the deaths of Charmaine, Aaleyn, Matilda, Wyatt, and Zaidok McLeod

Female·multiple injuries from motor vehicle collision (for all five deceased)

Charmaine McLeod died by intentionally driving her vehicle into an oncoming truck, killing herself and her four young children (aged 2-6). She had a longstanding history of complex mental health issues (Borderline Person…

psychiatryemergency medicinesystemcommunicationfluvoxamine
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