15 results
Male·Gunshot wounds to the head
This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…
36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…
Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…
22y · Male·ligature compression of the neck (hanging)
Lewis Weston, aged 22, died by suicide on 3 November 2020 while subject to a Community Treatment Order (CTO) for Schizoaffective Disorder. He presented with first-episode psychosis in 2017 and repeatedly refused antipsyc…
35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…
Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…
A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding as…
56y · Male·unascertained; presumed suicide by unknown means
Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 September 2016. The coroner found on the bala…
28y · Male·Neck compression consistent with hanging
A 28-year-old man with severe depression, persistent suicidal ideation and previous suicide attempts died by hanging in a mental health inpatient unit while under involuntary detention. Despite being assessed as high sui…
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on adm…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requir…
33y · Female·multiple injuries sustained in a train incident
A 33-year-old woman with schizoaffective disorder and chronic suicidality died by suicide after stepping in front of a train on 6 October 2009. She was an involuntary psychiatric patient at Northpark Private Hospital des…
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…
71y · Male·hypoxic brain injury due to hanging
A 71-year-old farmer with a 10-year history of major depressive disorder with melancholic features died by hanging on 22 July 2005, three days after admission to a private psychiatric hospital (Belmont) following a medic…
40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…
Paul Meech, a 40-year-old man with bipolar affective disorder, died of asphyxia caused by a seizure from severe alcohol intoxication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The …
3y · Male·smothering
A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequate. T…
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