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VIChospital2020-05-25

Finding into death of Chris Perdios

42y · Male·Aspiration pneumonia in the setting of impacted large bowel in a man with intell…

Chris Perdios, a 42-year-old man with intellectual disability, autism, and chronic constipation, died from aspiration pneumonia complicated by an impacted large bowel. He was admitted to hospital on 12 October 2018 with …

intensive careemergency medicinecommunicationsystemquetiapine
SAhospital2020-05-21

Coroner's Finding: JAKSA Stan

82y · Male·malignant mesothelioma (palliated)

Stan Jaksa, aged 82, died from malignant mesothelioma with palliation at Repatriation General Hospital. He was admitted with confusion and behavioral changes attributed initially to frontotemporal dementia but reassessed…

geriatric medicinepsychiatryquetiapine
TAShome2020-05-14

Coroner's Finding: Cashion, Brett Matthew

48y · Male·combined drug intoxication from morphine and quetiapine

Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphine. He was receiving daily Subutex in Tasmania from …

general practicepain medicinecommunicationsystemmorphine
VICcommunity2020-05-11

Finding into death of Jolanta Boyd

48y · Female·Multiple injuries sustained when struck by a train

Jolanta Boyd, a 48-year-old woman with documented mental health conditions including suicidal ideation, alcohol use disorder, and anxiety, died by suicide on 18 June 2018 when she jumped in front of a train at Windsor ra…

psychiatryemergency medicinecommunicationsystemalcohol
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July …

psychiatrysystemcommunicationcitalopram
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…

psychiatrygeneral practicecommunicationsystemphentermine
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient…

psychiatrycardiologysystemcommunicationquetiapine
NSWmental health2019-11-29

Inquest into the death of Harold EDWARDS (a pseudonym)

49y · Male·Hanging

A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …

psychiatrydiagnosticcommunicationtemazepam
SA2019-11-14

Coroner's Finding: SINGH Heidi Eileen Roseanne

14y · Female·electrocution

Heidi Singh was a 14-year-old Aboriginal girl who died by electrocution at a railway pylon on 21 August 2014. She had suffered from foetal alcohol spectrum disorder since early childhood, experienced multiple losses (par…

paediatricspsychiatrysystemcommunicationquetiapine
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone
NSWhome2019-10-04

Inquest into the death of C D

60y · Male·burn wounds and the consequences thereof

CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…

general practicepsychiatrydiagnosticcommunicationdiazepam
WAhome2019-09-27

Inquest into the Death of Paul STRANGE

30y · Male·ligature compression of the neck (hanging)

Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…

psychiatryemergency medicinecommunicationsystemduloxetine
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

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…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
VICmental health2019-09-19

Finding into death of Vanna Vassallo

68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall

Vanna Vassallo, a 68-year-old with schizophrenia, chronic comorbidities and documented high fall risk, died from complications of a subdural haemorrhage sustained in a fall at an aged mental health inpatient unit. She ha…

psychiatrygeriatric medicinepossibly_preventablefluphenazine decanoate
TAScommunity2019-09-09

Coroner's Finding: Wilson, Jacob Leigh

27y · Male·chest and abdominal injuries from single motorcycle crash

Jacob Wilson, aged 27, died from chest and abdominal injuries sustained in a motorcycle crash on 22 January 2018. He was travelling to a scheduled mental health appointment when he lost control of his motorcycle on a cur…

general practicepsychiatrycommunicationdiazepam
WA2019-08-20

Inquest into the Death of Judy Sonia BOLTON

44y · Female·acute myocardial infarction due to coronary thrombosis

A 44-year-old Aboriginal woman died from acute myocardial infarction (heart attack) due to coronary thrombosis while in custody at Bandyup Women's Prison in Western Australia. She had multiple cardiovascular risk factors…

cardiologyemergency medicinediagnosticsystemmetoprolol
VICcommunity2019-07-30

Finding into death of Caterina Fratto

45y · Female·Hanging

A 45-year-old woman with bipolar affective disorder, borderline personality disorder, anorexia nervosa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health…

psychiatrygeneral practicecommunicationdocumentationquetiapine
WA2019-07-11

Inquest into the Death of Annabel NICOL

50y · Female·ligature compression of the neck (hanging)

Annabel Nicol, a 50-year-old woman, died by ligature compression of the neck (hanging) in Bandyup Women's Prison on 15 June 2015. She was a remand prisoner with chronic alcoholism, depression, and suicidal ideation who h…

psychiatrycorrectional healthsystemdelaymirtazapine
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

Two remand inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate…

psychiatrydiagnosticcommunicationquetiapine
VIChome2019-07-02

Finding into death of William Davenport

48y · Male·Pulmonary fibrosis associated with scoliosis

William Ian Davenport, a 48-year-old man with Trisomy 4p, scoliosis, and multiple comorbidities died from pulmonary fibrosis associated with scoliosis. He presented with productive cough on 15 September 2017, treated wit…

general practiceemergency medicinesodium valproate
19101120

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