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QLDcommunity2026-08-11

Inquest into the death of James Michael Watson

34y · Male·Multiple gunshot wounds

James Michael Watson, aged 34, died from multiple gunshot wounds sustained during a police altercation outside the Greek Club in South Brisbane on 11 October 2022. He had long-standing mental health issues and polysubsta…

forensic medicinetoxicologymethamphetamine
VICaged care2026-07-29

Finding into death of Rosemary Elsie Harriet Jacoby

94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)

A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…

general practiceemergency medicinemedicationcommunicationbaclofen
TAShome2026-03-23

Coroner's Finding: de-identified ZA

51y · Female·Unintentional prescription drug poisoning due to central nervous system depressi…

A 51-year-old woman with chronic pain, depression, and longstanding medication misuse died from unintentional prescription drug poisoning. She had been prescribed high-risk combinations of opioids and benzodiazepines ove…

general practicepain medicineoxycodone
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…

psychiatryemergency medicinesystemdelaytapentadol
VIChospital2026-02-05

Finding into death of Max Peter McKenzie

15y · Male·Cardiorespiratory arrest of unknown aetiology complicating hypoxic ischaemic enc…

Max McKenzie, a 15-year-old with asthma and food allergies, died from cardiorespiratory arrest complicating hypoxic ischaemic encephalopathy after severe refractory anaphylaxis. After eating apple crumble containing nuts…

emergency medicineparamedicinedelaycommunicationadrenaline
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
VIChome2025-09-02

Finding into death of Mr IKL

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…

general practicepsychiatrydiagnosticmedicationgabapentin
VIChospital2025-03-28

Finding into death of Barbara Anne Deal

86y · Female·Pulmonary thromboembolism in the setting of deep leg vein thrombosis, secondary …

Barbara Deal, 86, died from pulmonary embolism secondary to deep vein thrombosis 17 days after lumbar spinal fusion surgery. Critical failures included: no repeat VTE risk assessments despite policy requirements; inconsi…

neurosurgeryinfectious diseasesmedicationsystemapixaban
VIChome2025-01-08

Finding into death of Ivy McGowan

28y · Female·Cerebral x-linked adrenoleukodystrophy

Ivy McGowan, a 28-year-old NDIS participant with cerebral x-linked adrenoleukodystrophy, died at home on 5 October 2023 from natural causes. She had experienced progressive deterioration from late 2022, with increasing n…

palliative caregeneral practicefentanyl
QLDhospital2024-11-08

Non-inquest findings into the death of SD

61y · Male·Lymphoma (CD30 positive T-cell lymphoproliferative disorder), medically managed

A 61-year-old man died from CD30-positive T-cell lymphoproliferative disorder (PTCL) after being incorrectly diagnosed and treated for Hodgkin lymphoma. Critical diagnostic information—a negative PAX5 immunohistochemistr…

haematologypathologydiagnosticcommunicationprednisolone
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, …

psychiatrygeneral practicecommunicationsystemtapentadol
WAhome2023-11-10

Inquest into the Death of Child ML (Name Subject to Suppression Order)

7y · Female·Pneumonia complicating a viral respiratory illness with acute combined drug effe…

Child ML, aged 7, died of pneumonia complicating viral respiratory illness with acute combined drug effect. She had severe cerebral palsy with complex care needs including PEJ tube feeding and multiple medications. At th…

paediatricsrespiratory medicinemedicationsystemcodeine
VIChome2023-10-10

Finding into death of Abdurrahman Coskun

53y · Male·Neck compression in the circumstances of hanging

A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …

psychiatrygeneral practicecommunicationsystemmirtazapine
NSW2023-08-23

Inquest into the death of Stefan Wakeman

55y · Male·ischaemic heart disease

Stefan Wakeman, aged 55, died of ischaemic heart disease while in custody at Metropolitan Remand and Reception Centre on 9 June 2019. Autopsy revealed significant coronary artery narrowing (40-50% to 70-80%) with emphyse…

correctional healthgeneral practicemethadone
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
VICcustody2020-12-23

Finding into death of Gary Hietanen

45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)

A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to…

emergency medicinecardiologycommunicationsystemmethadone
VIChospital2020-11-25

Finding into death of Eoghan Jerome Arnold

42y · Male·Hypoxic ischaemic brain injury secondary to cardiac arrest caused by massive pul…

A 42-year-old man died from hypoxic ischaemic brain injury following cardiac arrest due to a massive pulmonary embolism. He sustained a tibial fracture in a motor vehicle accident and underwent external fixation. He deve…

orthopaedic surgeryanaesthesiasystemenoxaparin
WAcommunity2020-10-02

Inquest into the Suspected Death of Jorn Jesper JENSEN

68y · Male·unascertained

A 68-year-old man with multiple chronic medical conditions including peripheral neuropathy, chronic pain, atrial fibrillation, dysphagia, and depression disappeared on 25 June 2017. He left home, drove his car to Lanceli…

general practicecardiologybuprenorphine
TAShome2020-06-30

Coroner's Finding: Hinley, David John

74y · Male·Mixed prescription drug toxicity (codeine, paracetamol, mirtazapine, promethazin…

A 74-year-old man with multiple chronic conditions including cerebellar ataxia, COPD, depression and anxiety died from mixed prescription drug toxicity. He had cognitive impairment affecting medication management and hab…

general practicepsychiatrycommunicationsystemcodeine
WA2019-11-14

Inquest into the Death of David Anthony RICE

49y · Male·multiple injuries

A 49-year-old remand prisoner died from multiple injuries after being pinned between a reversing truck and a coolroom wall in the prison industries yard. The deceased voluntarily offered to guide the truck as it reversed…

proceduralsupervisionparacetamol

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