49 results
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
42y · Female·Incised injury to the neck
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…
24y · Male·bronchopneumonia complicating oxycodone toxicity
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…
40y · Male·Toxic effects of a gas
Nathan Shanahan, a 40-year-old former ADF member, died from toxic gas inhalation in his vehicle. He had struggled with depression, anxiety, and PTSD following service in the Solomon Islands where he witnessed a sexual as…
40y · Female·Clozapine toxicity in a woman with cardiomegaly
A 40-year-old woman with depression, anxiety, alcoholism and undiagnosed cardiomegaly died from clozapine toxicity after obtaining the drug from a co-resident at a Peer Recovery Community. She was not prescribed clozapin…
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
51y · Male·unascertained; presumed sudden cardiac arrhythmia
Kenneth Stephens, a 51-year-old man with schizoaffective disorder, died from an unascertained cause while under involuntary psychiatric care. He presented with acute behavioural changes including excessive drinking, unus…
49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…
Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…
87y · Female·combined effects of pentobarbitone, oxazepam, amlodipine and zopiclone ingestion…
Mrs Patricia Shaw, aged 87, died from combined drug ingestion (pentobarbitone, oxazepam, zopiclone, amlodipine) with evidence of smothering and plastic bag asphyxia. This was a planned end-of-life death undertaken with h…
20y · Female·Asphyxia secondary to inhalation of helium
Lauren Pilkington, a 20-year-old postgraduate student, died by asphyxia from helium inhalation. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission …
53y · Female·Hypoxic brain injury due to hanging
A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her deat…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suic…
45y · Male·undetermined in a man in correctional services custody with a chronic history of…
Leister John Ross, a 45-year-old Aboriginal prisoner, died in Port Phillip Prison on 10 July 2014 from an undetermined cause in a man with chronic illicit drug use. Forensic pathology revealed pulmonary oedema, hepatic c…
68y · Female·Multiple injuries sustained in a fall
68-year-old woman with bipolar affective disorder and history of suicide attempts died by jumping from a car park rooftop on 14 April 2015. She had been discharged from psychiatric inpatient care to aged care on 2 March …
22y · Male·Multiple injuries secondary to fall from a height
Daniel Woodburn, a 22-year-old with first-episode psychosis presenting with command hallucinations, paranoia and depressed mood, was admitted as a voluntary patient to an unlocked inpatient unit at Orygen Youth Health on…
33y · Male·Mixed drug toxicity
Shaun Beagley, aged 33, died from mixed drug toxicity (heroin, methylamphetamine, benzodiazepines) while on overnight leave from E-PARCS psychiatric residential facility. He had been admitted following suicide attempts a…
43y · Female·mixed drug toxicity including methadone
43-year-old woman with long-standing opioid and benzodiazepine dependence died from mixed drug toxicity including methadone, amitriptyline, pregabalin, duloxetine, diazepam and paracetamol. Two GPs prescribed drugs witho…
29y · Female·global cerebral ischaemic injury in the setting of neck compression
Rebecca Poke, a 29-year-old woman with borderline personality disorder, died by suicide while an inpatient in Ward E of Casey Hospital on 2 September 2015. She had been admitted following a paracetamol overdose and was o…
60y · Male·medication overdose
Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
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