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VICmental health2010-09-16

Finding into death of Louise Litis

37y · Female·Hypoxic brain injury consequent upon hanging

Louise Litis, 37, died from hypoxic brain injury following a hanging at Northpark Private Hospital's Mother and Baby Unit on 7 December 2007. She had severe recurrent postpartum depression and had attempted suicide two w…

psychiatryintensive carediagnosticcommunicationsertraline
QLDcommunity2010-09-07

Simpson-Willson, John Douglas

56y · Male·head injuries inflicted by blunt force trauma

56-year-old John Douglas Simpson-Willson was fatally assaulted in Brisbane's Botanical Gardens on 3 June 2005 by Daniel Pattel, released from prison five days earlier. Pattel had expressed clear intentions to kill someon…

psychiatrycorrectional healthdiagnosticcommunication
NSW2010-09-03

Speering monica trent findings

40y · Male·Self-inflicted gunshot wound to the head

Trent Speering, a 40-year-old NSW paramedic, shot and killed his mother Monica, then shot himself on 11 June 2008. The coroner found that Trent suffered untreated paranoid personality disorder and depression. Despite mul…

psychiatrypsychologydiagnosticcommunication
QLD2010-08-31

Muir, Jason Andrew

36y · Male·Effects of hanging

Jason Muir, a 36-year-old remand prisoner with a history of mental illness and suicidal ideation, died by hanging in Arthur Gorrie Correctional Centre. He had been removed from suicide observation in June 2008 following …

psychiatrycorrectional healthsystemdelayquetiapine
VIChome2010-08-23

Finding into death of PC

20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin …

A 20-year-old man died from pulmonary oedema due to acute-on-chronic heart failure resulting from dothiepin overdose. He had complex mental health and substance use issues dating back to age 16. He was prescribed dothiep…

general practicepsychiatrydiagnosticmedicationdosulepin
SAcommunity2010-08-12

Coroner's Finding: BAIS Ricky James

38y · Male·ischaemic heart disease

Ricky James Bais, a 38-year-old man with paranoid schizophrenia and undiagnosed 75% left anterior descending coronary artery narrowing, died during police restraint. He had absconded from mental health detention at Noarl…

psychiatrygeneral practicesystemcommunicationdepot zuclopenthixol
VIChome2010-07-21

Finding into death of MF

29y · Female·Multiple stab wounds to the neck

A woman was fatally stabbed 12 times in the neck by her husband during an escalating family violence situation. She had disclosed family violence to Victoria Police on multiple occasions and to her General Practitioner. …

general practiceforensic medicinecommunicationsystem
QLD2010-07-09

Mataia, Tofia Josen

32y · Male·Cardiac arrest as a result of the combined effects of severe coronary atheroscle…

Tofia Mataia, a 32-year-old male with schizophrenia, died in custody at Capricornia Correctional Centre following restraint after assaulting officers. He collapsed during a 2-minute prone restraint by five officers. The …

psychiatryemergency medicinediagnosticcommunicationsodium valproate
QLDhome2010-06-09

Edwards, Peeta Louise Josephine

32y · Female·Opiate toxicity; toxic combination of morphine and codeine causing respiratory d…

Mrs Edwards, a 32-year-old woman with severe depression and psychiatric history, was found dead in bed. Autopsy revealed opiate toxicity with high levels of morphine and codeine. Toxicology expert opinion indicated morph…

general practicepsychiatrysystemdelaymorphine
QLDhome2010-06-09

Muller, Bradley John

45y · Male·overdose of quetiapine (Seroquel) augmented by alcohol

A 45-year-old man with schizophrenia and a decade-long history of repeated overdoses died from quetiapine (Seroquel) toxicity combined with alcohol. Critical failures occurred: multiple doctors prescribed large quantitie…

general practiceemergency medicinecommunicationsystemquetiapine
SAmental health2010-03-11

Coroner's Finding: SHIN Jeong

35y · Female·pulmonary thrombo-emboli

A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possi…

psychiatryemergency medicinedelayclozapine
QLDhome2010-03-05

Child at Mackay

15y · Female·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal girl died by suicide by hanging on 29 November 2007. She had a transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in su…

paediatricspsychiatrysystemdelayalcohol
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
VIC2010-02-08

Finding into death of Craig Walter Stevens

34y · Male·Hypoxic-ischaemic brain injury caused by hanging

Craig Stevens, aged 34, died from hypoxic-ischaemic brain injury following a suicide by hanging on 17 June 2008. Despite police intervention, critical delays in cutting the ligature around his neck prevented timely resus…

psychiatrygeneral practicesystemdelaysertraline
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He …

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
VIC2010-01-14

Finding into death of Sharkia Handy

14y · Female·hanging

Sharkia Handy, a 14-year-old girl in out-of-home care, died by hanging in December 2007. She had significant unaddressed mental health concerns including suicidal ideation, self-harm, and grief following peer suicides. T…

paediatricspsychiatrycommunicationsystem
QLDmental health2009-12-16

Shishko, Peter

47y · Male·abnormal heart rhythm (arrhythmia) induced by atherosclerosis, occurring in the …

Peter Shishko, a 47-year-old man with bipolar affective disorder, died in a mental health facility while in involuntary detention. He suffered a fatal cardiac arrhythmia on a background of severe coronary atherosclerosis…

psychiatrycardiologydiagnosticsystemdiazepam
SAmental health2009-12-04

Coroner's Finding: BLUNDEN Peter Ross

54y · Male·hanging by ligature

Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his adm…

psychiatryemergency medicinecommunicationsystemoxazepam
SAhospital2009-11-25

Coroner's Finding: WILMAN Joyce Millicent (aka Bracegirdle)

62y · Female·gastric necrosis and perforation due to strangulated diaphragmatic hernia

Joyce Wilman, 62, died from gastric necrosis and perforation due to strangulated para-oesophageal hernia whilst detained under Mental Health Act at Queen Elizabeth Hospital. She presented with vomiting and abdominal pain…

psychiatrygastroenterologydiagnosticcommunication
QLDhome2009-10-16

Anderson, Andrew Scott

14y · Male·gunshot wound to the head

Andrew Scott Anderson was a 14-year-old boy placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use…

psychiatrypaediatricsdiagnosticcommunicationmarijuana
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