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NSWcommunity2024-02-19

Inquest into the death of Omar Mohammad

33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity

Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…

emergency medicinetoxicologycommunicationdelaycocaine
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

26y · Male·Not able to be determined - skeletalised remains

Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 w…

emergency medicinepsychiatrycommunicationsystemolanzapine
VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

A 43-year-old man with schizophrenia, PTSD, and methamphetamine use died from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020…

psychiatryemergency medicinecommunicationdelayrisperidone
WAhospital2023-12-13

Inquest into the Death of Ashleigh Rebecca HUNTER

26y · Female·meningococcal infection (Neisseria meningitidis W strain) causing septicaemia

Ashleigh Rebecca Hunter, a previously healthy 26-year-old, died from meningococcal septicaemia (W strain) within 3 hours of arriving at Royal Perth Hospital. She presented with severe generalised pain (10/10), tachycardi…

emergency medicineinfectious diseasesdiagnosticsystemMDMA
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
TAShome2023-08-18

Coroner's Finding: Lukacevich, Anton

64y · Male·coronary atherosclerosis with early myocardial infarction

A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch sys…

cardiologyemergency medicinesystemcommunication
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
SAcommunity2023-05-26

Coroner's Finding: Latouche Mazzei, Lucas

5y · Male·acute upper airway obstruction from nectarine stone

Lucas Mazzei, aged 5 years, died on 27 March 2017 from acute upper airway obstruction caused by an uncut nectarine stone. While attending school, he was separated from his class during a science lesson and left watching …

emergency medicinepaediatricscommunicationsystemlamotrigine
TAShospital2023-05-05

Coroner's Finding: Pedler, Anne Helen

71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis

71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…

emergency medicinecardiologydiagnosticdelaycannabis oil
VIChome2023-03-16

Finding into death of Mr W

32y · Male·Hanging

Mr W, a 32-year-old man with lifelong anxiety, previous suicide attempts, and childhood trauma, died by hanging on 5 April 2019. He had been receiving care from a psychologist (Dr Cattapan) and GP (Dr Smith) since Decemb…

psychiatrypsychologycommunicationescitalopram
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…

psychiatryemergency medicinecommunicationdelaypaliperidone
VIChome2022-10-04

Finding into death of Baby R

3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…

Baby R, born at 38 weeks gestation to a mother with previous pregnancy losses, was small-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due t…

obstetricsmidwiferysystemcommunication
VIChome2022-08-26

Finding into death of David Patrick Hardisty

32y · Male·Mixed drug toxicity

A 32-year-old man with bipolar disorder and substance abuse history died from mixed drug toxicity (oxycodone 0.7 mg/L, tramadol, benzodiazepines, cannabis and amphetamines). Emergency services attended after his partner …

emergency medicineparamedicinecommunicationdiagnosticoxycodone
VICaged care2022-08-01

Finding into death of Phillip Charles Hodges

72y · Male·Choking on a food bolus

A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff lack of training in safe…

geriatric medicinespeech pathologydiagnosticcommunicationlamotrigine
TAScommunity2022-07-29

Coroner's Finding: Chamberlain, Pamela Jacqueline

55y · Female·asphyxia due to choking on food (steak)

A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…

emergency medicinepsychiatrysystemcommunicationdiazepam
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…

psychiatrycorrectional healthsystemcommunicationtramadol
QLDcommunity2022-06-29

Clarke, Hannah Ashlie; Baxter, Aaliyah Anne; Baxter, Laianah Grace; Baxter, Trey Rowan Charles; Baxter, Rowan Charles

Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …

Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…

emergency medicineparamedicinediagnosticcommunication
WA2022-06-17

Inquest into the 4 Deaths at Mount Augustus

heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…

Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…

emergency medicineforensic medicinesystemcommunication
VIChospital2022-05-17

Finding into death of Mr J

36y · Male·Multiple Sharp Force Injuries to Chest and Neck

Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with GP support after achieving 3 years …

general practicepsychiatrycommunicationdiagnosticpaliperidone

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