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VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …

psychiatryemergency medicinecommunicationsystemsertraline
NSWcommunity2025-03-20

Inquest into the death of Brent Pottinger

41y · Male·multiple blunt force injuries from fall from fourth floor of apartment block

Brent Reginald Pottinger, 41, died from multiple blunt force injuries after falling from a fourth-floor apartment while attempting to access his partner's balcony in the early morning of 13 May 2023. He had been arrested…

alcohol
VIChospital2025

Finding into death of TBL

81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…

An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…

psychiatrygeneral practicesystemdelayrisperidone
VIChospital2024-08-07

Finding into death of Georgios Stamkos

68y · Male·Complications of a witnessed airway obstruction from food bolus in a man with dy…

A 68-year-old man with dysphagia and bipolar disorder died from airway obstruction and aspiration pneumonia after choking on a sandwich brought by his wife during a supervised hospital meal. He had been admitted with wor…

psychiatryspeech pathologyrisperidone
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…

psychiatryintensive carecommunicationsystempaliperidone
VICcommunity2023-11-23

Finding into death of Melissa Louise Arbuckle

33y · Female·Mixed drug toxicity (propranolol, oxycodone, diazepam, temazepam, lurasidone, du…

Melissa Arbuckle, a 33-year-old woman, died from mixed drug toxicity (propranolol, oxycodone, diazepam, temazepam, lurasidone, duloxetine) by intentional overdose. She had been convicted of infanticide following her daug…

psychiatrygeneral practicepropranolol
VIChome2023-06-06

Finding into death of Michael Stephen Delaney

37y · Male·Plastic bag asphyxia

Michael Delaney, a 37-year-old man with treatment-resistant schizophrenia, died by plastic bag asphyxia while residing at supported independent living accommodation. He had multiple suicide attempts and was under the car…

psychiatrycommunicationsystemdiazepam
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
TAS2022-04-29

Coroner's Finding: Lavoipierre, Andre Marc

41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …

Andre Marc Lavoipierre, age 41, died on 26 June 2019 from exsanguination due to internal bleeding (ureter-iliac artery fistula or steady renal/bladder bleed). He fell at his supported residential unit on the morning of d…

psychiatrygeneral practicecommunicationdelayfluoxetine
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…

psychiatryemergency medicinesupervisioncommunicationolanzapine
VICcommunity2021-08-25

Finding into death of Garry Mark Wise

47y · Male·Hanging

A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…

psychiatrygeneral practicecommunicationsystemlurasidone
NSWcommunity2021-08-18

Inquest into the death of A F

24y · Male·multiple stab wounds to the chest that he inflicted upon himself

A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…

psychiatrygeneral practicesystemcommunicationlurasidone
WAhome2021-05-10

Inquest into the Death of Andre Walter BOND

42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…

Andre Walter Bond, a 42-year-old man with schizophrenia, schizoaffective disorder, Asperger's syndrome, and severe obesity, died from upper airway obstruction (choking) on food while dining at home. He had been recently …

psychiatryemergency medicinequetiapine
VICcommunity2021

Finding into death of Mr O

47y · Male·Hanging

A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the me…

psychiatrygeneral practicecommunicationsystemlurasidone
WAcommunity2019-08-01

Inquest into the Death of Matthew James BALE

38y · Male·Unascertained; death in the waters of the Indian Ocean off Rottnest Island

Matthew James Bale, a 38-year-old man, disappeared from Rottnest Island on 21 March 2016 while on holiday with his wife and parents. He had a history of depression, alcohol and drug addiction, and recent drug-induced psy…

psychiatryaddiction medicinecitalopram

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