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VIC2016-04-04

Finding into death of Werner Viertmann

83y · Male·Multiple injuries sustained in collision with train (pedestrian)

An 83-year-old man with probable Alzheimer's disease died after being struck by a train while attempting to climb from railway tracks. Despite living in aged care with documented cognitive decline and falls, he was permi…

geriatric medicinepsychiatrycommunicationsystem
WAhospital2016-03-24

Inquest into the Death of Jesse Richard DELLAR

17y · Male·ligature compression of the neck (hanging)

Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentionally overdosing on his ADHD med…

psychiatrygeneral practicediagnosticsystematomoxetine
VIChome2016-03-16

Finding into death of AA (Baby D)

0y · Female·head injuries

Twin infant died of head injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weigh…

general practicepaediatricsdiagnosticcommunication
NTcommunity2016-03-09

Inquest into the death of Ronald Donaldson

69y · Male·Blunt head trauma

Ronald Donaldson, a 69-year-old fencing contractor, was killed by Justin Osborne with a sledgehammer in Katherine on 3 December 2013. Osborne was experiencing untreated schizophrenia with acute psychotic symptoms and bel…

psychiatryemergency medicinedelaymarijuana
QLDcommunity2016-02-05

Cooper, Paul James - Non-inquest findings

41y · Male·Hanging

Paul Cooper, a 41-year-old man with bipolar disorder, died by hanging in August 2015, eleven days after psychiatric review. He had recently commenced Isotretinoin for severe acne, which coincided with development of para…

psychiatrygeneral practicecommunicationsystemisotretinoin
VIChome2016-01-18

Finding into death of Dean Wayne Wright

30y · Male·Mixed drug toxicity (codeine, tramadol, oxazepam, diazepam)

Dean Wright, a 30-year-old man with bipolar disorder, schizophrenia, anxiety and opioid dependence, died from mixed drug toxicity involving codeine, tramadol, oxazepam and diazepam. He systematically obtained prescriptio…

general practicepsychiatrysystemcommunicationcodeine
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

A 58-year-old man with chronic depression, anxiety and personality disorders died from combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam) after presenting to ED with suicidal…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…

psychiatryemergency medicinecommunicationdiagnosticantidepressants
WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
NSW2015-12-18

Inquest into the death of Officer A

43y · Female·External neck compression due to self-inflicted hanging

A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…

psychiatrypsychologydiagnosticsystemprescription medication
WAmental health2015-11-30

Inquest into the Death of Frances May COOPER

48y · Female·Head injury

Frances May Cooper, a 48-year-old woman with chronic paranoid schizophrenia, died from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Re…

psychiatryemergency medicineproceduralsystemrisperidone
VIChome2015-11-27

Finding into death of Sherry Ann Robinson

38y · Female·multiple stab injuries to the chest and abdomen

A 38-year-old woman was fatally stabbed by her former partner, Bradley Carolus, in May 2010. Three days before the homicide, Carolus had been apprehended by police under mental health legislation following a volatile epi…

psychiatryemergency medicinecommunicationsystemquetiapine
NSW2015-11-11

Inquest into the death of W

23y · Male·Hanging whilst suffering acute mental illness, most likely a first episode delus…

A 23-year-old man in custody died by hanging in May 2011 while experiencing untreated first-episode psychosis with paranoid delusions. He had expressed suicidal ideation on 20 April and was assessed by a Risk Interventio…

psychiatrycorrectional healthdiagnosticcommunication
NSW2015-10-27

Inquest into the death of Kevin Norris

38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…

Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Community Treatment…

emergency medicineintensive caredelaycommunicationmethamphetamine
NSWhome2015-10-23

Inquest into the death of Christine Drinnan

45y · Female·Multi-drug toxicity

Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …

general practicepsychiatrydiagnosticmedicationmorphine
NSWhome2015-10-23

Inquest into the death of Scott Clements

36y · Male·Unknown - advanced decomposition precluded determination

Scott Clements, a 36-year-old man with longstanding mental illness, depression, substance use disorder and multiple suicide attempts, was found dead at his home between 19 August and 14 October 2014. His body was in adva…

psychiatrygeneral practicecommunicationsystemmethamphetamine
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