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VIChospital2026-04-24

Finding into death of Mr JNY

Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis

JNY, a man with metastatic small cell carcinoma, COPD, and ischaemic heart disease, died from pulmonary thromboembolism and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undis…

palliative caregeneral practicesystemdesvenlafaxine
NSWhome2026-04-21

Inquest into the death of Michael

28y · Male·In keeping with Hanging

A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …

emergency medicineparamedicinesystemcommunicationvenlafaxine
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
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
VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethylvenlafa…

general practicerespiratory medicinesystemcommunicationgabapentin
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

Peter Owen Pilkington, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed …

emergency medicinetrauma surgerysystemmethamphetamine
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
VIC2025-03-12

Finding into death of Daniel Bryan Harvey

48y · Male·unascertained

Daniel Harvey, a 48-year-old man with morbid obesity, cirrhosis, diabetes, and polysubstance use including methadone and methamphetamine, was found unresponsive in immigration detention on 10 August 2020. He had complain…

cardiologygeneral practicedelaymethamphetamine
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
NSW2024-12-11

Inquest into the death of Terry Grady

59y · Male·Hanging

Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…

psychiatrycorrectional healthsystemdelaydesvenlafaxine
VIChospital2024-10-07

Finding into death of Danielle Julie Kaye Thomson

41y · Female·Neck compression and hanging

Danielle Thomson, a 41-year-old woman with complex medical and mental health conditions including cervical dystonia, bipolar disorder, borderline personality disorder, chronic pain, and alcohol use disorder, died by suic…

psychiatryaddiction medicinecommunicationsystembuprenorphine
VIChome2024-07-26

Finding into death of Mr KE

36y · Male·Neck compression secondary to hanging

A 36-year-old man with a history of depression, anxiety, and alcohol dependence died by suicide during the COVID-19 pandemic following job loss. He presented to a psychotherapist with suicidal ideation, multiple risk fac…

general practicepsychologysystemcommunicationsertraline
VIChome2024-07-05

Finding into death of BC J

32y · Female·Neck compression in the setting of self-suspension

A 32-year-old woman with a documented history of intimate partner violence died by self-suspension. She had reported ongoing physical, sexual and psychological abuse to police on 12 May 2020 and was assessed under mental…

psychiatryforensic medicinecommunicationsystemvenlafaxine
WAhome2024-05-28

Inquest into the Death of Cameron Anthony FYFE

27y · Male·gunshot injury to the head

A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, atte…

occupational and environmental healthpsychiatrysystemcommunicationdesvenlafaxine
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…

general practicepsychiatrymedicationdiagnosticcodeine
VICcommunity2024-04-19

Finding into death of HM I

32y · Male·Self inflicted incised injuries to wrists

A 32-year-old man with depression, anxiety, panic disorder, and cannabis use disorder presented to his GP on the day of his death reporting low mood, insomnia, social isolation, and daily cannabis use. He denied suicidal…

general practicepsychiatrycommunicationdesvenlafaxine
NTcommunity2024

Inquest into the death of Road Death 44 of 2024

54y · Male·Multiple blunt force injuries from motor vehicle collision

A 54-year-old male died in a motor vehicle collision on the Arnhem Highway near Humpty Doo on 24 August 2024. He was a sober, licenced driver travelling at the speed limit with no fatigue, distraction, or seatbelt concer…

desvenlafaxine
VICcommunity2023-11-23

Finding into death of Daryl Scott Perkins

31y · Male·Multiple injuries sustained in a motor vehicle incident (passenger)

A 31-year-old male passenger died from multiple injuries sustained in a motor vehicle collision. The driver, after consuming alcohol at a pub (blood alcohol level estimated 0.233-0.278% at time of collision), drove the v…

systemalcohol
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…

general practicepain medicinemedicationcommunicationtramadol
TAShome2023-05-10

Coroner's Finding: PQ de-identified

51y · Male·self-inflicted chest injuries due to gunshot wound to chest

A 51-year-old man with a 37-year history of depression and alcoholism died by self-inflicted gunshot wound. He had ceased anti-depressant medication (desvenlafaxine) in September 2019 without documented clinical reason, …

general practicepsychiatrycommunicationsystemdesvenlafaxine

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