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VIChospital2026-05-22

Finding into death of Stratos Ioannidis

45y · Male·focal coronary artery disease and cardiomegaly

Stratos Ioannidis, age 45, died at Maroondah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disor…

psychiatryemergency medicinecommunicationsystemolanzapine
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…

psychiatrypsychologycommunicationsystemalprazolam
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
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
NSWmental health2025-08-13

Inquest into the death of Allyson Bailey

42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…

Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…

emergency medicineintensive carediagnosticcommunicationbaclofen
VIChospital2025

Finding into death of Ms NXA

54y · Female·neck compression secondary to hanging

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
VIChospital2024-12-02

Finding into death of S K

25y · Male·Gunshot injury to the head

SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…

emergency medicinepsychiatrysystemdelaymethamphetamine
VICcommunity2024-11-15

Finding into death of Benjamin James Ralston

31y · Male·Mixed alcohol and drug toxicity (heroin, promethazine, benzodiazepines, 3-fluoro…

Benjamin Ralston, 31-year-old, died from mixed alcohol and drug toxicity involving heroin, promethazine, benzodiazepines, and 3-fluoromethamphetamine (3-FA). He was found unresponsive on a street after socialising and dr…

heroin
VIC2024-10-16

Finding into death of Jessica Anne Thomas

33y · Unknown·neck compression secondary to hanging

Jessica Anne Thomas, a 33-year-old gender-diverse person with complex psychiatric diagnoses including schizoaffective disorder, borderline personality disorder, and PTSD, died by hanging while remanded in custody at Dame…

psychiatryemergency medicinesystemaripiprazole
TAShospital2024-10-11

Coroner's Finding: Vieth, Karl Heinz

92y · Male·periprosthetic fracture of the left hip sustained from a fall from standing posi…

A 92-year-old man with complex cardiac history was admitted to Royal Hobart Hospital with chest pain and atrial fibrillation. He remained in the Emergency Medical Unit (EMU) for five days despite clinical deterioration, …

general medicineemergency medicinesystemdelaymelatonin
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
VICmental health2024-08-09

Finding into death of Con Kostantinou

63y · Male·Unascertained - natural causes. Cardiac arrest with secondary hypoxic-ischaemic …

A 63-year-old man with bipolar affective disorder, obstructive sleep apnoea, prostatic hyperplasia, and emphysema was admitted involuntarily to Northern Hospital on 24 March 2024 after exhibiting delirium and mania with …

psychiatrygeneral medicinediazepam
ACThospital2024-07-25

Inquest Into The Death Of Katherine Aurelia Alexander

34y · Female·multiple drug toxicity

Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 Feb…

psychiatryemergency medicinecommunicationsystemdosulepin
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

17-year-old Joshua Klumper died by hanging following cannabis withdrawal and workplace stress. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and…

psychiatryemergency medicinecommunicationsystemcannabis
VIChospital2023-07-31

Finding into death of Michael Stankic

29y · Male·Pulmonary thromboembolism secondary to deep venous thrombosis

A 29-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis (DVT) following a suicide attempt by hanging. He was admitted to ICU and appropriately commenced on prophylactic enoxaparin 40mg dai…

intensive carepsychiatrysystemdelayenoxaparin
VICmental health2023-06-22

Finding into death of Veronika (Veronica) Anastasia Kouros

31y · Female·Plastic bag asphyxia

31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospit…

psychiatrygeneral practicesystemproceduralquetiapine
VICmental health2023-05-22

Finding into death of Jennifer Gebert

49y · Female·Unascertained; most likely cardiac abnormality

Jennifer Gebert, a 49-year-old with long-standing mental illness and substance use disorder, died unexpectedly in an acute psychiatric unit on 6 December 2019. She presented to the ED intoxicated (BAC 0.159%) following b…

psychiatryemergency medicinealcohol
VICaged care2023-03-22

Finding into death of S M

91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…

A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…

geriatric medicinegeneral practicediagnosticmedicationdiltiazem

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