398 results
44y · Male·mixed drug toxicity
Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and somatic disor…
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…
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…
31y · Male·hanging
MC, a 31-year-old male with a history of drug-induced psychosis and substance abuse, died by hanging in May 2015 at the Metropolitan Reception and Remand Centre while in lawful custody. He had been transferred to the Men…
64y · Male·Multiple injuries sustained after jumping from a height
MB, a 64-year-old man with progressive major depression, died from multiple injuries sustained after jumping from a cliff at the Skillion near Terrigal. Over 18 months, his mental health deteriorated with depressive symp…
38y · Female·Complications of decompensated liver failure due to cirrhosis secondary to Hepat…
Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to re…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
53y · Female·self-inflicted hanging
Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…
24y · Female·hypoxic brain injury secondary to hanging
Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …
54y · Male·Extensive burns due to detonation of LPG gas cylinder
A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…
39y · Male·ligature compression of the neck (hanging)
A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…
32y · Male·asphyxia arising from neck compression from self-inflicted ligature strangulatio…
Glen Russell, 32, died by suicide in Cessnock Correctional Centre while on remand. He had a complex history including childhood sexual assault, schizophrenia diagnosis, heroin use, and recent self-harm episodes. Although…
46y · Male·Neck compression due to hanging
Jason Muehlfenzl, a 46-year-old man, died by hanging in his cell at Bathurst Correctional Complex on 31 July/1 August 2016. He had a documented history of suicidal ideation following his mother's death in 2014. On 31 Jul…
33y · Female·hanging, self-inflicted with intention of taking her own life
Naomi Watson Ley, a 33-year-old woman with a history of depression and borderline personality disorder, was admitted to Royal North Shore Hospital following suicidal ideation after medication changes (moclobemide to cita…
35y · Male·drowning following combined drug and alcohol intoxication
Brock Vince, a 35-year-old man with depression, obsessive-compulsive disorder, panic disorder, and alcoholism, died by drowning in his bathtub while intoxicated with alcohol and therapeutic-level psychiatric medications.…
31y · Male·bronchopneumonia and hypoxic brain injury following ligature compression of the …
31-year-old Moses Sokiri died on 26 October 2014 from bronchopneumonia and hypoxic brain injury following suicide by hanging at Greenwood train station on 12 October 2014. The deceased was in acute mental health crisis w…
36y · Male·hypoxic brain injury and myocardial ischaemia following cardiac arrest during re…
A 36-year-old man with methylamphetamine intoxication was restrained by civilians and police following a property damage incident. He experienced cardiac arrest during restraint and died from hypoxic brain injury and myo…
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs …
In September 2013, Mr John Evans (62) killed his wife Jillian after he experienced psychosis manifesting as delusions about chemical infestation of their home. The coroner found Mr Evans was psychotic at the time of deat…
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