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VIChome2024-03-07

Finding into death of Claire Louise Carroll

45y · Female·Neck compression secondary to hanging

Claire Louise Carroll, 45, died by hanging while experiencing severe untreated psychotic symptoms including auditory hallucinations, paranoid delusions, and persecutory ideation. She had complex mental health diagnoses (…

psychiatrygeneral practicesystemcommunicationclonazepam
NSWcommunity2024-02-20

Inquest into the death of Jasmynd Gibbs

33y · Male·Complications of methylamphetamine use

Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…

correctional healthpsychiatrysystemcommunicationmethamphetamine
VIChome2024-02-05

Finding into death of Ms KSI

22y · Female·Complications of cutaneous burns

A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws…

general practiceemergency medicinecommunicationsystem
TAScommunity2024-01-30

Coroner's Finding: Ryan, Robert John

35y · Male·Multiple organ failure—cause not determined to requisite standard

Robert John Ryan, a 35-year-old senior stockman, collapsed suddenly on 7 January 2015 at a farm gate near his workplace at Malahide in Tasmania, while driving his work utility during a normal workday. He presented with s…

toxicologyintensive carediagnosticdelayparoxetine
NSWcommunity2024-01-23

Inquest into the disappearance and suspected death of Bruce Robinson

72y · Male·The available evidence does not allow for any finding to be made as to the cause…

Bruce Robinson, a 72-year-old man with a history of non-Hodgkin's lymphoma, schizophrenia, psychosis, and dementia, died on 27 October 2022 after jumping from a ferry into Sydney Harbour. He had been non-compliant with h…

psychiatryemergency medicinesystemolanzapine
TAScommunity2024-01-22

Coroner's Finding: de-identified TX

30y · Male·Drowning due to jumping from the Batman Bridge

A 30-year-old man with opioid use disorder, anxiety, and depression died by suicide from jumping the Batman Bridge. He had been prescribed escalating doses of clonazepam (1-8mg daily) over three years by general practiti…

general practicepsychiatrydiagnosticsystemclonazepam
TAShome2024-01-18

Coroner's Finding: KT - deidentified

47y · Female·insulin and mixed drug toxicity, the result of actions undertaken by the decease…

A 47-year-old woman with depression and a history of suicidal ideation died from insulin and mixed drug toxicity after deliberately injecting insulin from her daughter's insulin pens. She had been seen by her GP seven ti…

psychiatrypsychologycommunicationsysteminsulin
VIChospital2024-01-18

Finding into death of Lily Grace Arbuckle

0y · Female·Head injury

Lily Grace Arbuckle, a 9-week-old infant, died from head injury sustained when her mother placed her on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and …

obstetricspaediatricsdiagnosticcommunication
NTcommunity2024

Inquest into the death of Domestic violence victim (Bush Camp, Karama)

47y · Female·Multiple blunt force injuries

A 47-year-old Aboriginal woman died from multiple blunt force injuries sustained during a prolonged violent attack by her domestic partner at a bush camp in Karama, NT on 17 January 2022. She had a documented history of …

forensic medicineemergency medicinecommunicationsystemalcohol
VIC2024

Finding into death of W B

59y · Male·Gunshot wound of head

A 59-year-old police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP ma…

general practicepsychiatrycommunicationsystemdiazepam
SAaged care2023-12-22

Coroner's Finding: LENS, Christopher

64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …

Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…

geriatric medicinespeech pathologysystemcommunication
WA2023-12-21

Inquest into the Death of Shane Nathan ROBERTS

41y · Male·Ligature compression of the neck (hanging)

Shane Nathan Roberts, aged 41, died by ligature compression (hanging) in Hakea Prison on 24 June 2019. He had pre-existing depression and anxiety treated with citalopram. A prison doctor referred him to the Mental Health…

correctional healthgeneral practicesystemdelaycitalopram
VICcommunity2023-12-20

Finding into death of Lachlan McMahon Cook

16y · Male·Hypoxic/ischaemic encephalopathy in the context of diabetic ketoacidosis

A 16-year-old with Type 1 Diabetes died from diabetic ketoacidosis (DKA) precipitated by acute gastroenteritis acquired while on a school trip to Vietnam. Despite reporting vomiting at 8am on 26 September 2019, Lachlan w…

endocrinologygeneral practicediagnosticcommunicationinsulin
VICcommunity2023-12-08

Finding into death of Ricky James Broughton

47y · Male·Complications of acute agitation in the setting of a prolonged struggle in an ac…

Ricky Broughton, a 47-year-old man with chronic treatment-resistant schizophrenia, died during police restraint while being transferred for involuntary psychiatric assessment. After moving from Geelong to Ballarat in Feb…

psychiatrygeneral practicecommunicationsystemquetiapine
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…

neurosurgerypsychiatrycommunicationsystemfentanyl
VIChospital2023-11-24

Finding into death of Vikki Michelle Prenc

59y · Female·Asphyxial aspiration with upper airways obstruction by vomitus

Ms Prenc, a 59-year-old woman with spina bifida, died from asphyxial aspiration with upper airway obstruction by vomitus while hospitalised for urosepsis. The critical clinical issue was a Goals of Care (GOC) document co…

general practicegeneral medicinecommunicationsystemondansetron
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…

psychiatrygeneral practicediagnosticsystemduloxetine
WAhospital2023-10-18

Inquest into the Death of Corazon Contreras KEELEY

71y · Female·complications of metastatic endometrial carcinoma, treated palliatively

Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…

gynaecologyoncologydiagnosticcommunication
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient p…

psychiatrypaediatricssystemcommunicationfluoxetine
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…

general practicepain medicinemedicationcommunicationtramadol
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