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NSW2022-10-12

Inquest into the death of Brenden Montgomery

36y · Male·Hypoxic Ischaemic Encephalopathy

Brenden Montgomery, aged 36, died from hypoxic ischaemic encephalopathy after hanging himself on 30 December 2019 while police were present outside his home. He had a long-standing history of depression and anxiety, prev…

communicationsystemescitalopram
WAhospital2022-10-07

Inquest into the Death of Justine PAINTER

51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…

Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…

gastroenterologypsychiatrycommunicationsystempaliperidone
NSWmental health2022-09-16

Inquest into the death of S B

81y · Male·cardiac arrest following neck compression due to hanging

An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…

psychiatrygeriatric medicinediagnosticcommunicationolanzapine
SAhome2022-08-15

Coroner's Finding: Bruns, Corbus Kenneth

64y · Male·sodium nitrite poisoning

A 64-year-old man on home detention bail died from intentional sodium nitrite poisoning. He had a documented history of depression, anxiety, and suicidal ideation. His GP noted he was 'pretty much suicidal' in February 2…

general practicepsychologycommunicationsodium nitrite
SAhospital2022-06-10

Coroner's Finding: Bertram, Kerry Anne

42y · Female·multiorgan failure complicating hyperthermia and metabolic acidosis following su…

A 42-year-old woman with long-standing depression, substance use issues, and multiple mental health presentations died from multi-organ failure following ingestion of caustic soda. She was found unresponsive at home on 1…

intensive carepsychiatryalcohol
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
TAS2021-11-25

Coroner's Finding: Nicholson, Dale Waverley

61y · Male·Unknown

Dale Waverley Nicholson, a 61-year-old man with a history of depression, alcohol and cannabis use, and a previous suicide attempt in 2012, disappeared from his home in New Norfolk, Tasmania on 10 December 2016. Despite e…

escitalopram
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Unknown·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
WAhome2021-09-09

Inquest into the Death of Amy Lee WENSLEY

24y · Female·Shotgun injury to the head

Amy Wensley died from a shotgun wound to the head on 26 June 2014. Whether self-inflicted or inflicted by another remains undetermined. Detectives prematurely concluded suicide on the night of death without thorough inve…

forensic medicinetoxicologydiagnosticcommunicationcitalopram
QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…

psychiatrycorrectional healthsystemdiazepam
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtain…

psychiatrypsychologysystemproceduralpentobarbitone
NSWhome2021-04-30

Inquest into the deaths of Gabriella THOMPSON and Tafari WALTON

27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…

Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for …

psychiatrygeneral practicecommunicationsystemmethamphetamine
VICcommunity2021-03-31

Finding into death of Bruce Vernon Taylor

53y · Male·Complications of old brain injury in prior motor vehicle incident

Bruce Vernon Taylor, 53, died from complications of a remote brain injury sustained in childhood motor vehicle accident. He lived in shared disability accommodation and received support through NDIS. In the 12 months bef…

general practiceneurologysodium valproate
SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…

psychiatrygeriatric medicinehydromorphone
VIC2020-01-15

Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …

oral and maxillofacial surgeryemergency medicinecommunicationsystemmethadone
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
VIChome2019-08-06

Finding into death of Angelina Alviano

67y · Female·Sudden unexpected death in epilepsy in a woman with schizophrenia and cardiomega…

A 67-year-old woman with epilepsy, schizophrenia, and cardiomegaly died suddenly and unexpectedly at home in disability accommodation. The coroner determined the cause as sudden unexpected death in epilepsy (SUDEP). The …

neurologypsychiatrylamotrigine
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…

psychiatrygeneral practicediagnosticcommunicationescitalopram
WAhome2019-05-10

Inquest into the Death of Matthew Neil Hardy TONKIN

24y · Male·bronchopneumonia complicating oxycodone toxicity

Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…

general practicepain medicinediagnosticcommunicationoxycodone

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