105 results
23y · Male·combined drug toxicity (oxymorphone, benzodiazepines, codeine, and morphine) in …
Jonas Jvirblis, a 23-year-old PhD student, died from combined drug toxicity (oxymorphone, benzodiazepines, codeine, and morphine) in the setting of sarcoidosis. He had a long history of substance abuse and anxiety disord…
57y · Male·Multiple fatal injuries following a fall from height onto rocks
A 57-year-old European-born man died by suicide after falling from a cliff in northern Tasmania in July 2014. He had experienced progressive mental health deterioration over 12 months, including depression, anxiety, and …
51y · Male·multiple gunshot wounds to the chest
Edward Wayne Logan, a 51-year-old Maori man with a history of violence, bipolar disorder, and personality disorder, died after being shot by police at Tewantin, Queensland on 23 November 2014. Following an argument with …
17y · Female·multiple injuries due to impact by train
A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clin…
28y · Female·combined drug toxicity (heroin and prescribed psychiatric medications)
Priscilla Stephenson, a 28-year-old Aboriginal woman with longstanding mental illness and polysubstance abuse, died from combined drug toxicity (heroin plus prescribed psychiatric medications) shortly after discharge fro…
69y · Female·Asphyxiation consistent with hanging
A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…
24y · Male·complications of ligature compression of the neck (hanging)
Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …
24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…
Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…
62y · Female·hyponatremia (low sodium level 114mmol/L) resulting in seizure, with aspiration …
A 62-year-old woman with chronic schizophrenia died from hyponatremia (sodium level 114mmol/L) resulting in seizure and aspiration during involuntary psychiatric admission. She had been on escitalopram (SSRI) for depress…
53y · Female·Combined drug toxicity (propranolol and insulin)
A 53-year-old registered nurse with longstanding depression, anxiety and benzodiazepine dependency died from combined drug toxicity (propranolol and insulin) in what was determined to be an intentional overdose. Ms Webst…
51y · Female·Aspiration pneumonia in a woman with Down syndrome and Alzheimer's dementia
Angela Thompson, a 51-year-old woman with Down syndrome and early-onset Alzheimer's dementia, died from aspiration pneumonia following a shoulder fracture. She was in DHS supported residential care when she suffered freq…
56y · Male·hypothermia
Robert Glaisher, a 56-year-old man with depression and significant alcohol abuse, presented to the ED on 5 July 2010 with acute confusion, agitation and visual hallucinations. He had a history of heavy alcohol consumptio…
40y · Male·Ligature compression of the neck in circumstances of being hanged
Adam Omerovic, a 40-year-old man with a long history of depression, substance abuse, and prior suicide attempts, died by hanging in a Melbourne Assessment Prison cell on 23 March 2010. He had been remanded on armed robbe…
46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)
A 46-year-old teacher, Gavin Lyle Woods, died by suicide after prolonged workplace stress and an undertreated major depressive disorder. He had been a deputy principal at Burpengary State School for only five months. Cli…
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 …
52y · Female·Hanging due to depression
Mrs B, a 52-year-old woman with a 17-year history of recurrent depression, suicidal ideation, and borderline personality traits, was admitted to Cairns Base Hospital Mental Health Unit on 11 March 2008 with escalating su…
47y · Male·Pulmonary thromboembolism in association with deep vein thrombosis
A 47-year-old man from Carnarvon underwent elective laparoscopic cholecystectomy at Geraldton Regional Hospital on 31 August 2009 after a 5-hour coach journey that morning. The VTE Risk Assessment Form correctly classifi…
19y · Female·asphyxiation
A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…
38y · Female·Pulmonary Thromboembolism
Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
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