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VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identif…

psychiatrygeneral practicesystemcommunicationmorphine
VIChospital2025-11-10

Finding into death of Jason Hosier

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…

emergency medicinepsychiatrycommunicationsystemmethadone
VIChome2025-03-14

Finding into death of Jonathan Mark Townsend

59y · Male·Unascertained

Jonathan Townsend, a 59-year-old Navy veteran with PTSD, alcohol use disorder, and multiple psychiatric comorbidities, died at home on 5 November 2021. The cause of death was unascertained despite autopsy and toxicology.…

trauma surgerypsychiatrycommunicationsystemdiazepam
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
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
NSWmental health2024-03-06

Inquest into the death of RA

64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging

A 64-year-old woman with a history of childhood trauma, anxiety and depression was admitted to an acute mental health unit (Kurrajong Unit) under involuntary care following a suicide attempt. Within 24 hours, she accesse…

psychiatryemergency medicinesystemproceduralmirtazapine
VIChome2023-02-01

Finding into death of J R

45y · Male·Mixed drug toxicity

Dr JR, a 45-year-old anaesthetist, died from mixed drug toxicity after self-administering intravenous propofol and alfentanil at home. He had access to anaesthetic agents through his workplace. The coroner found this was…

anaesthesiaoccupational and environmental healthpropofol
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

SJ, a 24-year-old man with recently diagnosed Stage 4B non-Hodgkin lymphoma and pre-existing depression managed by Orygen Youth Health, died by suicide on 22 September 2016 by jumping from the seventh-floor rooftop garde…

psychiatryhaematologycommunicationdelaymetoclopramide
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
NSWcommunity2022-07-05

Inquest into the deaths of Darren WALLACE and T B D

Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…

Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…

psychiatryemergency medicinesystemdelaysertraline
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relations…

general practicepsychiatrydiagnosticcommunicationmorphine
TAShome2021-10-08

Coroner's Finding: Reaks, Karen Tracey

49y · Female·combined prescription drug intoxication (zopiclone, amitriptyline, periciazine)

Karen Tracey Reaks, aged 49, died from combined prescription drug intoxication involving zopiclone, amitriptyline, and periciazine, with systemic lupus erythematosus as a contributing factor. She ingested medications in …

general practicepsychiatrysystemdelayzopiclone
VIChospital2021-08-16

Finding into death of David John Main

54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)

David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid depende…

pain medicineanaesthesiaketamine
VIChospital2021-03-19

Finding into death of BT

25y · Male·Multiple system failure and ingestion of sodium nitrite

BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He pre…

emergency medicinepsychiatrydiagnosticsystemsodium nitrite
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to …

psychiatryemergency medicinecommunicationsystemdextroamphetamine
VIChome2021-02-24

Finding into death of AAC

29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…

A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…

general practicetoxicologydiagnosticsystempregabalin
VICcommunity2021-02-23

Finding into death of Daniel Patrick Frawley

56y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

Daniel Frawley, a 56-year-old former AFL player and coach, died in a single-vehicle collision when his utility struck a tree at high speed (minimum 132 km/h) on a rural road. The coroner found he intentionally took his o…

psychiatryforensic medicinedesvenlafaxine
SAhospital2020-07-09

Coroner's Finding: DUNSTAN Carole Ann (Redacted)

70y · Female·end stage dementia

Carole Ann Dunstan, a 70-year-old woman with end-stage dementia, died of natural causes at Repatriation General Hospital on 17 June 2017 while subject to a Level 3 Inpatient Treatment Order. She had been admitted followi…

psychiatrygeriatric medicinerisperidone
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
VIChome2019-06-12

Finding into death of MKT

38y · Male·Toxicity to heroin

A 38-year-old man with a 24-year history of heroin addiction died from heroin toxicity shortly after release from prison. He had recently completed a 3-month custodial sentence and was released on 22 June 2018, dying on …

emergency medicinegeneral practicesystemcommunicationheroin

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