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VICmental health2019-09-19

Finding into death of Vanna Vassallo

68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall

Vanna Vassallo, a 68-year-old with schizophrenia, chronic comorbidities and documented high fall risk, died from complications of a subdural haemorrhage sustained in a fall at an aged mental health inpatient unit. She ha…

psychiatrygeriatric medicinepossibly_preventablefluphenazine decanoate
WAcommunity

Inquest into the Death of Kim Martin FRANKER

36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…

A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive dyskinesia), amphetamine-type stimulants,…

psychiatrygeneral practicecommunicationsystembenzhexol
VICmental health2015-12-07

Finding into death of Jeffrey John Hartwig

43y · Male·Pneumonia

Jeffrey John Hartwig, a 43-year-old with chronic schizophrenia and opiate dependence, died from pneumonia following cardiorespiratory collapse on an acute psychiatric inpatient unit. He was on multiple psychoactive medic…

psychiatryintensive caremonitoringcommunicationmethadone
NSWcommunity2015-06-10

Inquest into the death of Laurence Paul LANDER

23y · Male·open finding - not determined

A 23-year-old man with intellectual disability and chronic schizophrenia disappeared into bushland in 1982 and was presumed deceased. Clinical lessons include the importance of comprehensive discharge planning for vulner…

psychiatrysystemcommunicationstelazine
WAmental health2014-04-11

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

Amanda Gilbert, aged 47, died from bronchopneumonia with background ischaemic heart disease, chronic renal failure, and hypoxic brain injury from a 1985 hanging attempt. She had been an involuntary patient at Graylands H…

psychiatrygeneral medicinesystemdelaylithium
VIChospital2014-02-05

Finding into death of Margareta Snopek

67y · Female·Lithium toxicity with chest infection and bipolar disorder; Alzheimer's disease …

Mrs Snopek, aged 67 with bipolar disorder on long-term lithium, was prescribed coversyl (an ACE inhibitor) by Dr A. in January 2008 for hypertension. This combination is contraindicated as ACE inhibitors impair renal fun…

general practiceneurologymedicationdiagnosticlithium carbonate
SAhospital2013-09-19

Coroner's Finding: HOCKING Robert Nicholas

67y · Male·aspiration pneumonia with contributing chronic schizophrenia

Robert Nicholas Hocking, a 67-year-old man with treatment-resistant chronic schizophrenia, died from aspiration pneumonia during his final hospitalization at Royal Adelaide Hospital. He was a long-term inpatient at Glens…

psychiatrygeneral medicineolanzapine
VICcommunity2013-02-14

Coroner's Finding: Peter Raven Fisher

55y · Male·Immersion

Peter Fisher, a 55-year-old man with schizophrenia and depression, died from immersion after becoming homeless. Discharged from The Alfred Hospital in February 2007 to supported accommodation without a Community Treatmen…

psychiatrygeneral practicecommunicationsystemsertraline
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…

emergency medicinepsychiatrymedicationsystemclonazepam
SA2006-06-16

Coroner's Finding: HODSON Lawrence John

63y · Male·complications from carcinoma of the lung

Lawrence John Hodson, a 63-year-old man detained in custody at Glenside Campus under the Criminal Law Consolidation Act, died from complications of lung cancer. He had been diagnosed with cancer in 2003 and was receiving…

oncologyrespiratory medicinesalbutamol
WAmental health2001-02-02

Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

Giovanni Mario Franco, a 30-year-old man with schizophrenia, died on 10 March 1998 at Graylands Hospital from acute cardiac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed se…

psychiatryintensive caremedicationflupenthixol decanoate
SAaged care2000-11-07

Coroner's Finding: CZEKAJLO Helena

69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…

Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …

geriatric medicineemergency medicineproceduralcommunicationfluphenazine decanoate

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