997 results
22y · Female·plastic bag asphyxia, possibly contributed to by neck compression
A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asp…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
35y · Male·Fentanyl toxicity
David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…
26y · Female·Toxicity to Pentobarbitone
Dannika Smith, aged 26, died from pentobarbitone toxicity after deliberate self-ingestion. She had Borderline Personality Disorder with documented suicidal ideation and had previously attempted suicide. She imported pent…
Male·Police use of lethal force; coroner found in each case the officers acted approp…
This multi-death inquest examined five police shootings in Queensland (2013-2014) where all deceased had mental health histories. The coroner found officers acted appropriately in each case but made 19 recommendations to…
13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…
A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…
41y · Male·Fulminant sepsis (Klebsiella pneumoniae) with multi-organ failure complicating s…
A 41-year-old man with newly diagnosed severe Crohn's colitis was prescribed 6-mercaptopurine (6-MP) after only 5 days of hospital treatment. He had a homozygous TPMT gene deficiency (present in ~0.3% of population) that…
21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia
A 21-year-old man with complex congenital heart disease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, duri…
83y · Female·Hyponatraemic encephalopathy due to adverse effects of citaprolam and duloxetine…
An 83-year-old woman with pre-existing SIADH-related chronic hyponatraemia died from hyponatraemic encephalopathy following antidepressant therapy. Critical clinical lessons include: (1) the importance of accessing prior…
42y · Male·Multiple injuries sustained in motor vehicle crash
A 42-year-old man with schizoaffective disorder subject to a Community Treatment Order died in a single-vehicle motor crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern…
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferr…
34y · Male·drowning
A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and…
27y · Female·hanging, self-inflicted with intention of taking own life
A 27-year-old Aboriginal woman with borderline personality disorder died by suicide within hours of discharge from an emergency department. She presented after her GP attempted to schedule her under the Mental Health Act…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…
33y · Female·blunt impact injuries to neck and chest
A 33-year-old woman with depression, anxiety, and emerging psychotic symptoms presented to the ED on two consecutive days (26 and 28 October 2013). Following the first presentation, she was assessed by a psychiatric nurs…
41y · Female·mixed drug and alcohol toxicity
Karen Louise Richards, 41 years old, died from mixed drug and alcohol toxicity on 11 January 2014. She had consumed heroin (evidenced by 6-MAM metabolite), alcohol, benzodiazepines, and other prescription medications. He…
22y · Female·compression of the neck consistent with hanging
22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…
79y · Male·Head and neck injuries from blunt force trauma
Mr Risto Pedevski, a 79-year-old man, was fatally assaulted by his son George in November 2014 during a dispute over a gas hot water system. George had a long-standing diagnosis of schizophreniform disorder and paranoid …
23y · Male·Unable to be determined from available evidence
Benjamin Stephens, aged 23, went missing on 18 March 2004 from rural NSW and was confirmed deceased in 2016 when his skull was discovered via DNA matching. In the months before his disappearance, Ben developed symptoms c…
Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…
This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia fr…
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