848 results
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
32y · Female·Compression of the neck
FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…
42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…
Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…
53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…
BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…
68y · Male·Unascertained
JNY, a 68-year-old man, died from unascertained causes between 1-4 September 2020. His wife, RBT, administered temazepam-laced biscuits causing unconsciousness, then wrapped and placed him in a non-operational freezer. R…
59y · Male·Urosepsis and aspiration pneumonia (with Trisomy 21 as underlying condition)
Donald Raymond Muir, a 59-year-old man with Trisomy 21, non-verbal autism, dementia and epilepsy living in specialist disability accommodation, died of urosepsis and aspiration pneumonia. He had experienced progressive f…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity
Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug toxicity. Postmortem toxicology revealed high-co…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
44y · Male·Airways obstruction with mucous plugging secondary to quadriplegia post accident
Lachlan Rayner, a 44-year-old man with quadriplegia from a 2019 spinal injury, died from airways obstruction due to mucous plugging and pneumonia. He was a specialist disability accommodation resident receiving in-home c…
31y · Male·Drowning
Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…
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 …
21y · Male·drowning
A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …
44y · Male·bronchopneumonia in the setting of combined drug effect
Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…
66y · Female·Pneumonia (with Trisomy 21 and dementia as contributing conditions)
Voula Hristeas, a 66-year-old woman with Down syndrome, dementia, and intellectual disability, died of pneumonia on 31 March 2024 at her supported disability accommodation home. She had been admitted to hospital on 21 Fe…
75y · Female·Presumed drowning; insufficient evidence to establish cause to requisite legal s…
This coronial finding addresses the disappearance of Jeanne D'Arcy, aged 75, from Cottesloe Beach, Western Australia on 13 April 2022. Following a distressing day that included legal consultation about her disputed housi…
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