173 results
38y · Male·Toxic effects of morphine in a setting of benzodiazepine dependency
A 38-year-old man with chronic pain, mental illness, and benzodiazepine dependency died from morphine toxicity. He obtained multiple benzodiazepines and opioids from five different doctors through 'prescription shopping'…
Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …
This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…
37y · Male·combined ethanol and drug toxicity
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…
63y · Male·cerebral infarction
John Arthur Burns, a 63-year-old man with frontotemporal dementia and motor neurone disease, died from cerebral infarction on 17 September 2006 while in Westminster Aged Care Facility after only 12 days of residence. Des…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
2y · Female·pneumonia in a toddler with enlarged tonsils and presence of codeine in blood
Elanur Koc, a 2-year-old with a history of recurrent throat infections and enlarged tonsils, died from pneumonia. Significant codeine was detected in her blood, urine, liver, and stomach contents, with codeine also prese…
37y · Male·Mixed drug toxicity (heroin, methadone and diazepam) in a man with coronary arte…
Michael Gledhill, 37, died from mixed drug toxicity involving heroin, methadone, and diazepam, complicated by pre-existing coronary artery disease. He was enrolled in a methadone maintenance program but continued illicit…
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …
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…
81y · Male·bronchopneumonia
An 81-year-old man with dementia, congestive cardiac failure, chronic lung disease and hip fractures died of bronchopneumonia four days after discharge from palliative care to a nursing home. While an administrative erro…
29y · Female·Invasive aspergillosis
A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…
65y · Male·acute right subdural haematoma
Sidney Brunt, aged 65, died from an acute right subdural haematoma caused by excessive, unmonitored anticoagulation with warfarin. His general practitioner, Dr A., prescribed warfarin for atrial fibrillation but failed t…
Female·Drowning (suicide)
Melissa Maree Blake died by suicide by drowning on 16 January 2007 while receiving community-based treatment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental He…
36y · Male·morphine toxicity
A 36-year-old man with morbid obesity, possible sleep apnoea, and respiratory symptoms died from morphine toxicity after taking three 100mg MS Contin tablets within 6 hours, despite being opioid-naïve. He presented to ED…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)
Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…
Unknown·Erfinna Lay: Aspiration resulting from Acute Multiple Drug Toxicity; John Quirk:…
Two young people died from acute multiple drug toxicity in 2005. Erfinna Lay (22, female) died from aspiration after ingesting chloral hydrate prescribed to her partner. John Quirk (27, male) died from doloxene overdose …
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