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QLD2017-02-10

Sloan, Dane Benjamin

24y · Male·Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged

Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Although CCTV monitore…

psychiatryemergency medicinesystemdelayamitriptyline
VICmental health2017-02-07

Finding into death of Esther Ng Kit Ching

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…

psychiatrycommunicationdelaymirtazapine
WAcommunity2017-01-05

Inquest into the Death of Radinka MIHAJLOVIC

47y · Female·Multiple injuries from being struck by a train; death determined to be suicide

A 47-year-old woman with bipolar affective disorder and PTSD, originally from Bosnia, died by suicide by stepping in front of a train on 1 May 2012. She was subject to a Community Treatment Order at the time. Critical cl…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2017

Finding into death of Harold George Nolan

73y · Male·Stab wound to the neck

Harold Nolan, 73, was fatally stabbed in the neck by his ex-wife Renee Nolan while asleep at home. Ms Nolan was his full-time carer following his 2013 stroke and was experiencing severe carer fatigue, mental health deter…

general practicepsychiatrycommunicationdelayantidepressants
ACThospital2016-12-16

AN INQUEST INTO THE DEATH OF PAUL FENNESSY

21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…

Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January 2010. He presented to the Emergency Department that afternoon after…

emergency medicinepsychiatrycommunicationsystemmethadone
NSWaged care2016-12-16

Inquest into the death of Frederick PEISLEY

58y · Male·blunt force head injury

Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of h…

psychiatrygeneral practicecommunicationsystempaliperidone
QLDcommunity2016-12-08

Floyd, Leah Elizabeth

48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…

A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …

neurologypsychiatrycommunicationsystemdiazepam
VICcommunity2016-12-05

Finding into death of Miroslaw Dziczkowski

40y · Male·UNDETERMINED - natural causes (most probably natural disease; starvation could n…

Miroslaw Dziczkowski, a 40-year-old man with paranoid schizophrenia managed under a Community Treatment Order, disappeared in January 2013 after withdrawing $7300 and relocating to a caravan park without notifying his me…

psychiatryforensic medicinesystemdelayzuclopenthixol decanoate
SAmental health2016-11-17

Coroner's Finding: ALCOCK, Ross Matthew

22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…

A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observations, he hung himself using an electrical cord in his wardrobe. The ward layout ha…

psychiatryintensive caresystemcommunicationolanzapine
VICcommunity2016-11-17

Finding into death of Maria Elizabeth Valler

56y · Female·asthma

Maria Valler, a 56-year-old woman with intellectual disability and autism who was living in Department of Health and Human Services (DHHS) supported accommodation, died from acute asthma while returning from a walking ex…

general practicepsychiatrycommunicationsystemseretide 250/25 mcg
VIC2016-11-07

Finding into death of Troy Daniel Saint

29y · Male·mixed drug toxicity including heroin

Troy Daniel Saint, a 29-year-old man with amphetamine and opioid dependence, died of mixed drug toxicity including heroin while admitted to The Melbourne Clinic for voluntary detoxification. Critical failures occurred: (…

addiction medicinepsychiatrycommunicationsystemheroin
SAhospital2016-10-10

Coroner's Finding: MACMILLAN Kay Meredith

62y · Female·end-stage heart failure due to cardiac amyloidosis

A 62-year-old woman with end-stage cardiac amyloidosis died from cardiogenic shock approximately 90 minutes after being placed on a Level 1 inpatient treatment order. She had wished to discontinue treatment, reflecting h…

cardiologypsychiatrydiagnosticcommunicationmirtazapine
WA2016-10-07

Inquest into the Death of Gerardus Gerritt HEIJNE

49y · Male·Ligature compression of the neck (hanging)

A 49-year-old sentenced prisoner died by suicide via ligature compression of the neck at Acacia Prison in Western Australia. The deceased had a psychological profile characterised by denial and minimisation of adverse ex…

psychiatrygeneral practicedelaycitalopram
TASmental health2016-10-07

Coroner's Finding: Weily, Richard Maurice

85y · Male·Probable pneumonia following a hip fracture (comminuted fracture of right acetab…

Richard Weily, 85, with Lewy-body dementia, Parkinson's disease, and cardiac disease, was admitted to Roy Fagan Centre (RFC) mental health facility on 13 June 2013 under Mental Health Act provisions for management of acu…

general practicegeriatric medicinesystemdelayamiodarone
VIChome2016-10-07

Finding into death of Milica (Mary) Minchev

48y · Female·Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazep…

A 48-year-old woman with epilepsy, depression, anxiety and documented drug dependence died from combined toxicity of oxycodone, benzodiazepines, amitriptyline and other drugs. Over 12 months pre-death, she obtained medic…

general practicepsychiatrydiagnosticmedicationoxycodone
WAhome2016-09-30

Inquest into the Death of Janene DEVINE

48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…

A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…

neurologygastroenterologysystemdelay
TAScommunity2016-09-30

Coroner's Finding: Westbrook, Eden Jayde

15y · Female·asphyxia due to hanging

Eden Jayde Westbrook, a 15-year-old high school student, died by suicide on 17 February 2015. She had experienced depression for some time without formal diagnosis, had a history of self-harm and suicide attempts, and ha…

psychiatrypaediatricssystemdelay
WA2016-09-27

Inquest into the Death of Baby Z

0y · Male·unascertained

Baby Z, born to a serving prisoner on 3 March 2011, died suddenly on 3 April 2011 at Bandyup Women's Prison at one month of age. Despite extensive forensic investigation, the cause of death remained unascertained, though…

obstetricsneonatologycommunicationdelaymethadone
SA2016-09-22

Coroner's Finding: HENEKER Scott Maxwell

36y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restrain…

Scott Maxwell Heneker, aged 36, died from hypoxic ischaemic encephalopathy due to cardiac arrest occurring during physical restraint by a homeowner. The deceased had entered the homeowner's house without permission while…

psychiatryemergency medicinedelaycommunicationmethamphetamine
NSW2016-09-12

Inquest into the death of M

15y · Female·hypoxic brain damage due to multiple drug toxicity

A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma from childhood ab…

emergency medicinetoxicologydelaysystemheroin
130313250

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