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TAS2023-05-22

Coroner's Finding: Hyde-Wyatt, Michael Phillip

61y · Male·Pulmonary aspiration of gastric contents (post seizure) due to chronic communica…

Michael Phillip Hyde-Wyatt, aged 61, died from pulmonary aspiration of gastric contents following a seizure. He had chronic communicating hydrocephalus and encephalomalacia. At 1:30am, support worker Julie Magrath observ…

general practiceneurologycommunicationdelay
TAShome2023-05-10

Coroner's Finding: PQ de-identified

51y · Male·self-inflicted chest injuries due to gunshot wound to chest

A 51-year-old man with a 37-year history of depression and alcoholism died by self-inflicted gunshot wound. He had ceased anti-depressant medication (desvenlafaxine) in September 2019 without documented clinical reason, …

general practicepsychiatrycommunicationsystemdesvenlafaxine
VIChome2023-05-10

Finding into death of P A

26y · Female·Pentobarbitone toxicity

PA, a 26-year-old veterinary nurse, died by suicide on 12 September 2021 using pentobarbitone accessed from her workplace. She had a history of depression and anxiety managed by her GP with antidepressants, but had becom…

general practicepsychiatrysystempentobarbitone
VIChome2023-05-04

Finding into death of Jodie Overstead

34y · Female·Multi drug toxicity

Jodie Overstead, a 34-year-old with epilepsy, anxiety, and chronic pain, died from multi-drug toxicity involving tramadol, codeine, amitriptyline, benzodiazepines and other drugs. She engaged in 'doctor shopping', obtain…

general practicepain medicinediagnosticmedicationtramadol
NSWhome2023-04-26

Inquest into the death of AX

70y · Female·Cause of death could not be determined - available evidence does not allow a fin…

A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…

forensic medicinecardiologysystemdelaycandesartan
TAShome2023-04-20

Coroner's Finding: Young, Luke Trevor

42y · Male·mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapin…

Luke Trevor Young, 42, died from mixed prescription drug toxicity (sertraline, amlodipine, lamotrigine, quetiapine) in a suicide by overdose. He had severe, longstanding bipolar II disorder with chronic suicidality, comp…

psychiatrygeneral practicesystemdelaysertraline
VICcommunity2023-04-19

Finding into death of J L

15y · Female·Hanging

A 15-year-old girl with major depressive disorder and bulimia nervosa died by suicide in June 2019. She had received treatment from a private psychologist from 2017-2018 within the constraints of a GP Mental Health Care …

psychologygeneral practicecommunicationsystem
VIChome2023-04-14

Finding into death of Jonathan Travis Palmer

36y · Male·Bronchopneumonia in a man with epilepsy

Jonathan Palmer, a 36-year-old man with epilepsy and intellectual disability living in a group home, died from bronchopneumonia on 24 February 2018. On 23 February, he developed respiratory symptoms (coughing, runny nose…

neurologygeneral practicecommunicationsystemlamotrigine
VIChome2023-04-13

Finding into death of Martin William Sheahan

57y · Male·Gunshot wounds to the head and abdomen

Martin Sheahan, 57, was fatally shot by Glenn Usher-Clarke at his home on 26 January 2022. Usher-Clarke, who held a NSW firearms licence and permit to acquire, legally purchased a shotgun in Victoria on 17 December 2021 …

general practicepsychiatrycommunicationsystemmirtazapine
SA2023-04-06

Coroner's Finding: Chilcott, Zhane Andrew Keith

13y · Male·Hanging

Zhane Chilcott, age 13, died by suicide at a residential care facility after 12 years in state care with 18 placements. The coroner found multiple systemic failures: inadequate scrutiny of his first placement with LB des…

paediatricsgeneral practicesystemcommunication
QLDcommunity2023-04-06

Spence, John Norman- Non-inquest findings

59y · Male·Multiple injuries due to motor vehicle collision (motorcyclist)

John Norman Spence, 59, died from multiple injuries sustained in a motorcycle collision with a Mercedes sedan driven by an 89-year-old man with undiagnosed vascular dementia. The driver had an expired medical certificate…

general practicegeriatric medicinecommunicationsystem
TAShome2023-04-03

Coroner's Finding: De-identified HJ

71y · Female·starvation

A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check and found her severely malnourished, mentally unwell, and unable to care …

psychiatrygeneral practicecommunicationsystem
VIChome2023-03-30

Finding into death of Suong Van Nguyen

51y · Male·COVID-19 pneumonia

Suong Van Nguyen, a 51-year-old worker at a chicken processing plant, died from COVID-19 pneumonia during home isolation in August 2020. He tested positive on 31 July, reported shortness of breath on 2 August, then becam…

infectious diseasesgeneral practicecommunicationsystem
VICaged care2023-03-22

Finding into death of Margaret Alice Cook

88y · Female·Complications of a stage 3 sacral pressure ulcer in a woman with dementia

Margaret Alice Cook, an 88-year-old woman with end-stage dementia, died from complications of a stage 3 sacral pressure ulcer at a palliative care unit. She had resided at Crofton House Supported Residential Services (SR…

geriatric medicinegeneral practicesystemcommunicationflucloxacillin
VICaged care2023-03-22

Finding into death of S M

91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…

A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…

geriatric medicinegeneral practicediagnosticmedicationdiltiazem
WA2023-03-13

Inquest into the Death of Frank ALBERT

46y · Male·atherosclerotic heart disease

Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…

cardiologyemergency medicinesystemcommunicationquetiapine
VIChome2023-02-27

Finding into death of Jayden Kain Wright

24y · Male·Combined drug toxicity (clonazepam, diazepam, methadone, tramadol, pregabalin)

Jayden Kain Wright, a 24-year-old Aboriginal man, died from combined drug toxicity involving clonazepam, diazepam, methadone, tramadol, and pregabalin. Following a motor vehicle collision in 2020, he developed opioid add…

general practiceforensic medicinediagnosticsystemclonazepam
NT2023-02-24

Inquest into the death of Bernard Hector

31y · Male·self-inflicted hanging

Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…

psychiatrycorrectional healthcommunicationsystem
VICaged care2023-02-23

Finding into death of H D

87y · Female·Complications following a medication administration error in a woman with multip…

An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…

geriatric medicinegeneral practicemedicationsystemrisedronate
VIChome2023-02-22

Finding into death of Anna Lawrence

64y · Female·Combined toxicity to alcohol and baclofen

Anna Lawrence, 64, died from combined toxicity of alcohol and baclofen on 30 April 2020. She had a 40+ year history of alcohol dependency, borderline personality disorder, depression, and multiple suicide attempts. Baclo…

psychiatrypsychologysystembaclofen
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