997 results
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
Female·self-inflicted death
Emily, a child in out-of-home care since infancy, died by suicide in 2014. She had early childhood trauma, attachment difficulties, and anxiety managed by a psychologist from age 5. Critical clinical lessons: (1) Complet…
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…
36y · Male·Combined effect of gunshot wounds to the chest and abdomen
Paul Lambert, 36, was shot by NSW Police on the Pacific Highway after attacking and stabbing his former girlfriend Dr J. multiple times. He had a longstanding pattern of intimate partner violence, stalking, emotional abu…
89y · Female·Blunt force head injury on a background of ischaemic and valvular heart disease
An 89-year-old woman with dementia and cardiac disease died from blunt force head injury sustained during an assault by another resident with alcohol-related dementia in an aged care facility. The resident had a document…
Ligature compression of the neck (hanging) in 12 cases; one open finding
This complex coronial inquest examined 13 Aboriginal children and young persons who died by suicide in the Kimberley Region between 2012–2016. The coroner found 12 deaths were suicides and one open finding. Common contri…
39y · Male·septicaemia following self-administered intravenous injection of faeces
A 39-year-old Aboriginal man with schizophrenia, personality disorder, and substance dependence died from septicaemia after self-injecting faeces into his vein while an involuntary mental health patient. He obtained a sy…
32y · Female·hanging
Fiona Burke, aged 32, died by hanging on 17 March 2017 following a prolonged history of family violence in her relationship with Darren Mather. The death occurred in a context of escalating intimate partner violence, alc…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…
36y · Female·Nicotine toxicity
Rachel Mihail, a 36-year-old with a complex psychiatric history including PTSD, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing sui…
24y · Male·seizure (epileptic)
Mohammad Nasim Najafi, a 24-year-old Afghan detainee with well-controlled epilepsy, died from a seizure after missing multiple doses of carbamazepine in the days preceding his death. He was held in immigration detention …
61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…
A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …
38y · Female·neck compression (hanging)
RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to Bloomfield Hospital on 12 April 2015 following an overdose with stated…
27y · Male·combined drug toxicity (U-47700 and etizolam)
Mark Sach, aged 27, died from combined drug toxicity involving U-47700 (a synthetic opioid 7.5 times more potent than morphine) and etizolam (a benzodiazepine 10 times more potent than diazepam), obtained via internet pu…
22y · Female·Sudden Unexpected Death in Epilepsy (SUDEP)
22-year-old woman with epilepsy, cognitive disability and schizophrenia died of Sudden Unexpected Death in Epilepsy (SUDEP) during respite care. She experienced a nocturnal seizure while sleeping at a disability support …
19y · Female·self-inflicted hanging
Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detai…
25y · Male·unable to determine
Tyrone Frederick MacQueen disappeared on 1 July 1994 at age 25. He had chronic schizophrenia with poor medication compliance, recent psychiatric hospitalization, expressed suicidal ideation, self-harm (wrist cutting), de…
70y · Male·combined effects of severe pulmonary emphysema, ischaemic heart disease and rece…
A 70-year-old man with severe COPD, dementia and a history of sexually inappropriate behaviour died following an assault by another resident with dementia. The coroner found institutional failures in care standards inclu…
43y · Female·acute toxic effects of amitriptyline
A 43-year-old woman with depression was admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health asse…
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…
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