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VICmental health2022-12-12

Finding into death of Scott Adam Brown

50y · Male·Hanging

A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary to Parkinson's disease and its treatment…

psychiatryneurologysystemcommunicationmadopar
NSW2022-12-06

Inquest into the death of Jason RADFORD

48y · Male·Fatal cardiac arrhythmia which was the result of obstructive sleep apnoea

Jason Radford, a 48-year-old First Nations man, died of fatal cardiac arrhythmia secondary to obstructive sleep apnoea while in custody at Junee Correctional Centre. He had multiple comorbidities including obesity, type …

cardiologygeneral practicemethadone
VIChome2022-12-01

Finding into death of Reece John Pullen

27y · Male·Multiple injuries sustained in a fall from height

Reece Pullen, 27, died from multiple injuries sustained in a fall from a seventh-floor balcony on 27 October 2021. He had a history of drug-induced psychosis following methamphetamine use, treated at Orygen Youth Health …

psychiatryemergency medicinearipiprazole
VIChome2022-10-27

Finding into death of Elizabeth Judith Robyn Wilms

29y · Female·Assault with blunt force injuries resulting in widespread bruising and traumatic…

Elizabeth Wilms, age 29, died between 1-5 July 2016 from fatal assault while in an abusive intimate relationship with Alexander Freeburn. Freeburn was the subject of an unexecuted NSW parole warrant for 541 days. The war…

forensic medicinetoxicologysystemdelaygamma hydroxybutyrate
WAhospital2022-10-07

Inquest into the Death of Justine PAINTER

51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…

Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…

gastroenterologypsychiatrycommunicationsystempaliperidone
VIChospital2022-09-07

Finding into death of Mr AB

17y · Male·Hypoxic ischaemic encephalopathy due to hanging

A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…

psychiatryemergency medicinesystemcommunicationquetiapine
VIChome2022-08-31

Finding into death of B L

28y · Male·neck compression consequent upon hanging

A 28-year-old man with severe personality disorder, substance use history, and recent suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide threats and high-lethal…

psychiatryemergency medicinecommunicationsystemsodium valproate
TAShome2022-08-18

Coroner's Finding: Daw Rodney Keith

63y · Male·acute blood loss due to self-inflicted sharp force incisional wounds of the thro…

A 63-year-old man with multiple chronic conditions including psoriatic arthritis, depression, prostate cancer, and recent dental issues died by self-inflicted sharp force wounds while on approved leave from a mental heal…

psychiatryemergency medicinecodeine
NSW2022-08-18

Inquest into the death of Gavin Ellis

31y · Male·hanging

Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…

psychiatrycorrectional healthdiagnosticcommunicationaripiprazole
NSWcommunity2022-07-15

Inquest into the death of C S

5y · Male·Presumed drowning

CS, aged 5 years 9 months, died by presumed drowning on 2 March 2017 in the Murray River, Moama NSW. His mother LS, who was mentally unwell and using ice, forcibly held him underwater. Multiple agencies—FACS, NSW and Vic…

paediatricspsychiatrydiagnosticsystemmethamphetamine
TAShospital2022-07-01

Coroner's Finding: CL de-identified

33y · Female·hanging

A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon monoxide poisoning attempt. The coroner found that discharge…

psychiatryemergency medicinediagnosticcommunicationsertraline
TAShome2022-06-20

Coroner's Finding: Williams, Julie Gaye

59y · Female·mixed prescription drug and alcohol toxicity (ethanol, diazepam, fluoxetine, and…

Julie Gaye Williams, 59, died from mixed prescription drug and alcohol toxicity with aspiration of gastric contents. She had extensive psychiatric history including depression, PTSD, bipolar disorder, and alcohol depende…

psychiatrygeneral practicealcohol
WAcommunity2022-06-09

Inquest into the Death of Desmond Edward JACK

33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)

Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 M…

psychiatryemergency medicinesystemmirtazapine
VIC2022-04-04

Finding into death of Naser Vukovic

42y · Male·Incised injury to the neck resulting in exsanguination and air embolism

Naser Vukovic, a 42-year-old prisoner with severe psychotic symptoms and dual P1/S3 risk ratings, died by self-inflicted neck laceration in Melbourne Assessment Prison on 8 June 2016. Despite two prior self-harm incident…

psychiatrycorrectional healthsystemdelayquetiapine
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…

psychiatryemergency medicinecommunicationsystemquetiapine
VIC2022-03-28

Finding into death of Deva Rebecca Frijlink

42y · Female·Choking on a food bolus

Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…

speech pathologyemergency medicinecommunicationsystemdiazepam
NSW2022-03-07

Inquest into the death of Ronald Reeves

70y · Male·The combined effects of the complications of ventilation associated pneumonia, a…

Ronald Reeves, a 70-year-old man on remand at Goulburn Correction Centre, was found unconscious on 22 April 2019 and transferred to Canberra Hospital where he died on 17 May 2019. The cause of death was complications of …

intensive careemergency medicinequetiapine
NSWmental health2022-02-01

Inquest into the death of Camilla MARGOLIS

34y · Female·multiple blunt force injuries

Camilla Margolis, 34, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 2…

psychiatryemergency medicinecommunicationsystemmirtazapine
TAScommunity2022-01-28

Coroner's Finding: AZ 2022 TASCD 60

16y · Male·Multiple blunt traumatic injuries from fall from height

A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had previous…

psychiatrycommunicationdiagnosticfluoxetine
WAhospital2022-01-17

Inquest into the Death of Peter Johnnie YOUNG

Male·Complications of alcohol and hepatitis C-related liver disease

Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…

hepatologygastroenterologysystemdelayquetiapine
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