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VICmental health2018-09-17

Finding into death of Paquita Goldberg

87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…

Paquita Goldberg, an 87-year-old woman with dementia, BPSD, and paranoia, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February…

psychiatrygeriatric medicinecommunicationsystemdesvenlafaxine
VICmental health2018-09-14

Finding into death of Lynette Roberts

49y · Female·Motor vehicle accident related multi trauma including a severe head injury

Lynette Roberts, a 49-year-old with schizophrenia, died from motor vehicle collision while wandering aimlessly on a main street in Dunolly on 16 December 2010. She had blood alcohol level 0.16% and was wearing inappropri…

psychiatrysystemcommunicationclozapine
QLDcommunity2018-09-11

Giorgio, Pasquale

54y · Male·Ischaemic cardiomyopathy following a period of restraint on a background of morb…

A 54-year-old man with schizophrenia, homelessness, and morbid obesity was arrested for wilful exposure and disorderly conduct. During restraint in the prone position with handcuffs, he struggled for several minutes. Alt…

emergency medicineforensic medicinediagnosticcommunicationflupenthixol
NSWmental health2018-09-07

Inquest into the disappearance and suspected death of Christine Joyce Dorothy Young

40y · Female·The medical cause of death was unable to be determined. Manner of death: uninten…

Christine Young, a 40-year-old Aboriginal woman with paranoid schizophrenia, absconded from a locked mental health inpatient unit and walked into desert scrubland where she died. Critical clinical lessons include: (1) fa…

psychiatryemergency medicinediagnosticcommunicationpaliperidone
TAShome2018-08-31

Coroner's Finding: Green, Paul William

66y · Male·carbon monoxide poisoning due to inhalation of exhaust gases from a lawn mower

Paul William Green, a 66-year-old retired engineer with longstanding depression, anxiety, PTSD, and chronic alcohol abuse, died by intentional carbon monoxide poisoning from a lawn mower exhaust. He had a prior suicide a…

psychiatrygeneral practicecommunicationsystemantidepressant medication
NSW2018-08-31

Inquest into the death of MC

31y · Male·hanging

MC, a 31-year-old male with a history of drug-induced psychosis and substance abuse, died by hanging in May 2015 at the Metropolitan Reception and Remand Centre while in lawful custody. He had been transferred to the Men…

psychiatrycorrectional healthcommunicationsystemolanzapine
QLD2018-08-10

Harmer, Jay Maree

38y · Female·Complications of decompensated liver failure due to cirrhosis secondary to Hepat…

Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to re…

gastroenterologypalliative carecommunicationdelaybuprenorphine
VIChome2018-08-06

Finding into death of Samuel Jack Morrison

24y · Male·Combined drug toxicity (heroin, benzodiazepine and others)

Samuel Morrison, 24, died from combined drug toxicity involving heroin, benzodiazepines and other substances. He had a long history of depression, anxiety and illicit drug use, and had recently been discharged from psych…

psychiatrygeneral practicesystemdelayheroin
NSWcommunity2018-07-30

Inquest into the death of Courtney Topic

22y · Female·gunshot wound to the chest

Courtney Topic, a 22-year-old woman with undiagnosed schizophrenia in acute psychosis, was fatally shot by police in February 2015 after leaving home with a large knife. She was unable to understand or respond to police …

psychiatryemergency medicinecommunicationsystemfluoxitane
NSWhome2018-07-27

Inquest into the death of Alissa Campbell

26y · Female·Multiple drug toxicity

Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …

general practiceaddiction medicinediagnosticmedicationcodeine
NSWcommunity2018-07-27

Inquest into the disappearance and suspected death of Kellie Anne Levitski

38y · Female·Unable to be determined

Kellie Anne Levitski disappeared on 31 March 2014 from her father's property near Bega, NSW. She had schizoaffective disorder requiring intensive mental health support, depot antipsychotic injections, and multiple medica…

psychiatrysystemdelay
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…

psychiatrygeneral practicecommunicationsystemrisperidone
SAhospital2018-07-19

Coroner's Finding: ROSS Chrystal Jessica

24y · Female·hypoxic brain injury secondary to hanging

Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…

psychiatrygeneral practicecommunicationdiagnosticfluvoxamine
NSW2018-07-13

Inquest into the death of Fenika Junior Tautuliu Fenika (Junior Fenika)

24y · Male·Massive blood loss caused by incised wounds of left upper extremity

A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …

psychiatryemergency medicinecommunicationsystemamisulpride
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

David Geoffrey Godley, aged 30, died from exsanguination due to self-inflicted multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression…

psychiatryemergency medicinedelaymethamphetamine
QLD2018-06-28

Hamilton, Blair Andrew

54y · Male·Extensive burns due to detonation of LPG gas cylinder

A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…

psychiatrygeneral practiceproceduralcommunicationvenlafaxine
WAhome2018-06-27

Inquest into the Death of Brook Damian CAIN

39y · Male·ligature compression of the neck (hanging)

A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

A premature newborn died from severe head injuries inflicted deliberately by his teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had …

neonatologypaediatricscommunicationsystem
QLD2018-06-20

Holstein, Zachary James David

23y · Male·Hypoxic-ischaemic encephalopathy due to hanging

Zachary James David Holstein, age 23, died by suicide by hanging in Woodford Correctional Centre on 8 February 2016 (declared extinct 12 February 2016). He had a history of substance abuse, self-harm, and mental health d…

psychiatrycorrectional healthdelaysystemmirtazapine
NThospital2018-06-19

Inquest into the death of Naomi Smith

26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis

Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…

psychiatryintensive caresystemdelay
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