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VIC2022-02-01

Finding into death of Travis Thomas Young

42y · Male·hanging

A 42-year-old prisoner with generalised anxiety disorder and chronic tinnitus causing significant distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff re…

psychiatrygeneral practicesystemdelaymethadone
VIChome2022-01-31

Finding into death of Leeanne Matheson

52y · Female·Mixed drug toxicity (methadone, pregabalin, valproic acid, benzodiazepines)

A 52-year-old woman with chronic pain, epilepsy, and opioid dependence died from mixed drug toxicity after prescribed methadone, pregabalin, valproic acid, and benzodiazepines. She was admitted to Box Hill Hospital on 12…

addiction medicinegeneral practicemedicationcommunicationmethadone
VICcommunity2022-01-20

Finding into death of YLM

78y · Male·Ruptured abdominal aortic aneurysm

A 78-year-old man died from rupture of a previously undiagnosed 7.1cm abdominal aortic aneurysm. A CT scan ordered for suspected renal colic incidentally discovered the aneurysm and recommended vascular review. The GP ap…

general practiceradiologycommunicationsystem
VIChospital2022-01-20

Finding into death of Ann-Maree Manno

57y · Female·Pulmonary thromboembolism

Ann-Maree Manno, 57, died from pulmonary thromboembolism 8 days after laparoscopic gastric band surgery. She had significant risk factors: obesity (BMI 37.9), history of unprovoked DVT in 2007 and 2016, and recent surger…

bariatric surgeryanaesthesiacommunicationsystemheparin
VIChospital2022-01-20

Finding into death of H I

49y · Female·Acute myocardial infarction secondary to giant-cell arteritis and atherosclerosi…

49-year-old woman died from acute myocardial infarction secondary to giant-cell arteritis of coronary arteries. On 26 November, she presented to her GP with left-sided chest pain described as atypical and unlikely ischae…

general practiceemergency medicinediagnosticsystemmetoclopramide
VIChome2022-01-12

Finding into death of Linda-Jane Margaret Tatterson

40y · Female·combined drug toxicity (clomipramine, sertraline, diazepam, and quetiapine)

Linda-Jane Tatterson, aged 40, died from combined drug toxicity involving clomipramine, sertraline, diazepam, and quetiapine. She had a longstanding history of depression, OCD, and recurrent overdoses between 2014-2016. …

general practicepsychiatrycommunicationsystemclomipramine
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relations…

general practicepsychiatrydiagnosticcommunicationmorphine
VIChome2022-01-03

Finding into death of Patricia Jocelyn Eve Grant

83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction

Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…

general practicegeriatric medicinediagnosticsystem
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
VIChome2022

Finding into death of TCW

43y · Female·Neck compression

TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disor…

psychiatrypsychologysystemdelayfluoxetine
NSWcommunity2021-12-23

Inquest into the deaths of Judith CHRUPALO and Christopher CLEE

73y · Female·Unknown due to decomposition

Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …

geriatric medicinepsychiatrydiagnosticcommunication
WA2021-12-21

Inquest into the Death of James Alexander TILBURY

77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…

James Tilbury, a 77-year-old long-term prisoner, died from early pneumonia while receiving palliative care for an atypical brain meningioma. He had complex chronic conditions including COPD, prostate cancer, ischaemic he…

palliative careneurosurgerycommunicationsystemdexamethasone
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
VIChome2021-12-21

Finding into death of Geoffrey Alan Locks

50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…

A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…

ENT surgeryoncologysystemcommunicationmethadone
NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …

general practiceemergency medicinemedicationcommunicationmethadone
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
VIChome2021-12-17

Finding into death of B H

49y · Male·hanging

A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that h…

psychiatrypsychologycommunicationsystemantidepressant medication
TAShome2021-12-03

Coroner's Finding: Summers, Damian

42y · Male·hanging, an action taken by himself with the intention of ending his life

A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural island where his partner and children had left. He had poor insight into his mental illn…

psychiatrygeneral practicecommunicationsystemolanzapine
QLD2021-11-30

Williams, Craig Leeton

45y · Male·Recurrence of ventricular fibrillation due to Brugada Syndrome

Craig Williams, 45, suffered an out-of-hospital cardiac arrest in 2015 due to presumptive Brugada Syndrome. He survived with severe hypoxic brain injury and spent 10 months rehabilitating at Cairns Hospital, where he was…

cardiologyrehabilitation medicinecommunicationsystemamitriptyline
WAhospital2021-11-29

Inquest into the Death of Miss T (Name Subject to Suppression Order)

16y · Female·acute abdominal obstruction secondary to adhesions associated with severe pelvic…

A 16-year-old Aboriginal girl died on Christmas Day 2016 from acute abdominal obstruction secondary to severe pelvic inflammatory disease caused by untreated gonorrhoea. Miss T presented to the ED twice with abdominal pa…

emergency medicinegeneral practicediagnosticsystemcannabis
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