28y · Male·Hanging
Dylan Bell, 28, died by hanging following discharge from Redland Hospital ED where he presented with acute psychosis, suicidal and homicidal ideation, and made three self-harm attempts by strangulation. Despite a concern…
57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…
Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…
54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine
JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…
27y · Male·heroin toxicity
A 27-year-old man died from heroin toxicity while on home detention bail. He had a history of depression, anxiety, and substance use (cannabis, methamphetamine, heroin). During home detention, he was compliant, engaged w…
39y · Male·mixed drug toxicity (methadone, benzodiazepines, olanzapine, zopiclone)
Jason Hosier, a 39-year-old man with complex mental health and substance use history, died from mixed drug toxicity following discharge from Sunshine Hospital. He was subject to an inpatient temporary treatment order and…
27y · Female·Hanging
Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…
47y · Male·Unascertained; most likely cardiac arrhythmia possibly triggered by obstructive …
David Horne, a 47-year-old man with bipolar disorder, schizoaffective disorder, and severe obstructive sleep apnoea, died suddenly at Maroondah Hospital while under compulsory psychiatric treatment. He experienced two ep…
42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…
Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…
64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…
Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…
47y · Male·Combined drug toxicity (heroin, amphetamines, hydroxyrisperidone, olanzapine)
Jay Joseph Harrison, a 47-year-old homeless man with schizophrenia and substance use disorder, died from combined drug toxicity involving heroin, amphetamines, hydroxyrisperidone, and olanzapine. He was found unconscious…
77y · Female·Complications of malnutrition in a woman with paranoid delusions
A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory t…
54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…
Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa
Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…
32y · Female·Compression of the neck
FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…
64y · Male·Unascertained natural causes
Paul Christopher George, a 64-year-old man with Borjeson-Forssman-Lehman Syndrome and dysphagia, died unexpectedly on 17 June 2024 while in the care of a support worker. He experienced repeated coughing fits during the d…
41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity
Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
21y · Male·unascertained
Samaan Salah Tilmiz Elsamin, a 21-year-old with severe treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and extremely challenging violent behaviours, died at Joondalup Health Campus …
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
Monique Jacinta Gomez, a 48-year-old woman with schizoaffective disorder and a mechanical aortic valve, died from intracerebral haemorrhage while receiving anticoagulation therapy for a recent embolic stroke. She was adm…
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