1,172 results
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…
47y · Male·Hanging
A 47-year-old man with newly diagnosed schizophrenia died by hanging. He had presented with paranoid delusions and was engaged with mental health services in February 2017. Critical deficiencies were identified in the me…
29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…
A 29-year-old woman with a history of childhood and intimate partner violence died from mixed drug toxicity (GHB, methylamphetamine, amphetamine, diazepam). She had multiple mental health diagnoses including PTSD, depres…
17y · Female·Complications of acute asthma in the setting of an allergic response
Catherin D'Rozario, 17 years old, died from complications of acute asthma triggered by anaphylaxis after consuming food containing sesame at a restaurant on 25 August 2019. Despite known allergies to nuts, sesame, fish a…
35y · Male·Hanging
Brett McDonnell, a 36-year-old man, died by hanging in January 2018 while subject to a Community Corrections Order and facing pending criminal charges. He had a history of depression treated with Pristiq since 2015, but …
48y · Male·Coronary atherosclerosis with acute cardiac event
Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…
Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…
Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …
30y · Male·unascertained
Daniel James Clement, a 30-year-old man with schizophrenia on a Psychiatric Treatment Order, disappeared from his mother's home in late May 2017 and was found deceased on the Murrumbidgee River in November 2017. His caus…
38y · Male·asphyxiation by ligature
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
26y · Male·unascertained; suspected suicide by firearm
Nicholas Daniel Ficarra, aged 26, disappeared on 14 January 2012 from his family farm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 200…
68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…
A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…
51y · Female·drowning
Laura Golding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay withou…
1y · Male·head injury
Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and…
50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity
A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…
27y · Male·Hanging
A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents as both perpetrator and victim in relationships, leading to…
54y · Female·mixed drug toxicity
A 54-year-old nurse with chronic pain from a 1990 back injury died from mixed drug toxicity involving morphine, codeine, doxylamine and nitrazepam. She was prescribed multiple CNS depressants for years despite being desi…
45y · Female·Compression of the neck in circumstances of hanging
Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…
45y · Male·unascertained
Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…
88y · Female·Complications of fractured neck of femur
An 88-year-old woman with advanced dementia died from complications following a fractured neck of femur sustained in a fall caused by another resident with vascular dementia in a secured aged care unit. The fall occurred…
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