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ACThome2020-02-24

Inquest into the death of Joanne Lea LOVELOCK

53y · Female·Combined effects of alcohol, amitriptyline, and methadone

Joanne Lovelock, a 53-year-old woman with chronic pain, died from combined effects of alcohol, amitriptyline, and methadone on Christmas Day 2015. She had developed opioid dependence while receiving legitimate pain manag…

general practicepain medicinesystemcommunicationalcohol
TAShome2020-02-18

Coroner's Finding: Evans, Conor Maclaren

19y · Male·mixed drug toxicity (methadone and diazepam)

A 19-year-old male died from mixed drug toxicity following ingestion of illicit methadone and diazepam. He was a regular user of illicit substances and prescription medications obtained without medical supervision. He ha…

general practiceforensic medicinesystemcommunicationmethadone
NSWaged care2020-02-11

Inquest into the death of Neville Clutton

78y · Male·complications of head injuries; antecedent cause: dementia

An 78-year-old man with dementia died from head injuries sustained in a push by his roommate, also with dementia, at an aged care facility. The deceased had multiple prior incidents with the aggressor starting in Novembe…

geriatric medicinegeneral practicediagnosticcommunicationrisperidone
WA2020-02-05

Inquest into the Death of Tania Marie HODGKINSON

48y · Female·Ligature compression of the neck (hanging)

Tania Marie Hodgkinson, a 48-year-old Aboriginal woman, died by suicide via ligature compression while remanded at Bandyup Women's Prison on 23 March 2017. She had been admitted with heroin withdrawal symptoms, grief fro…

psychiatrypsychologycommunicationsystemheroin
VIChome2020-01-31

Finding into death of X Y

27y · Female·Combined drug toxicity

XY, a 27-year-old woman, died from combined drug toxicity on 21–22 December 2016 at a friend's house in Melbourne. She had a history of opioid use, depression, and anxiety following a violent crime. She was enrolled in r…

general practiceaddiction medicinesystemmethamphetamine
VICcommunity2020-01-31

Finding into death of Francis John Stewart

38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…

A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…

general practiceendocrinologydiagnosticcommunicationprednisolone
VICaged care2020-01-30

Finding into death of Adele Di Quinzio

86y · Female·Sepsis complicating sacral decubitus ulceration in the setting of recent surgica…

Mrs Di Quinzio, an 86-year-old woman with multiple comorbidities, was discharged from hospital to a supported residential service (SRS) after hip fracture surgery. She required two-person assistance for mobility and was …

geriatric medicineorthopaedic surgerysystemcommunicationcefalexin
VIChome2020-01-29

Finding into death of Caitlin-Lei Alaya

44y · Female·Combined drug toxicity (elevated pregabalin, temazepam, oxazepam, ibuprofen, mel…

Caitlin-Lei Alaya, a 44-year-old woman with fibromyalgia, PTSD, depression and suicidal ideation, died from combined drug toxicity (elevated pregabalin, temazepam, ibuprofen, meloxicam). She survived a suicide attempt on…

general practiceemergency medicinemedicationsystempregabalin
QLDPodcast2020-01-24

Willersdorf, Maria

87y · Female·Hypoxic-ischaemic encephalopathy secondary to cardiac arrest, with valvular hear…

An 87-year-old woman died following a CT-guided epidural injection at a private radiology clinic. Although she had undergone the procedure for spinal pain, the radiologist performed an epidural injection at the T12 level…

radiologypain medicinediagnosticproceduralbupivacaine
VIC2020-01-15

Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …

oral and maxillofacial surgeryemergency medicinecommunicationsystemmethadone
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…

psychiatrygeneral practicecommunicationsystemphentermine
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
VIChome2020

Finding into death of Julian Victor Charles Bareuther

68y · Male·PLASTIC BAG AND NITROGEN GAS ASPHYXIA

68-year-old man with terminal, inoperable pancreatic cancer died by asphyxiation using a plastic bag and nitrogen gas. He sought access to Voluntary Assisted Dying (VAD) through his GP, Dr C., who assessed him as mentall…

general practicepalliative caresystem
NSWhome2019-12-20

Inquest into the deaths of TC and SN

Female·Hanging

This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…

paediatricspsychiatrycommunicationsystem
NSWhospital2019-12-13

Inquest into the death of Luca RASO

13y · Male·Peritonitis secondary to ruptured gangrenous acute appendicitis

Luca Raso, a healthy 13-year-old boy, died from peritonitis secondary to ruptured gangrenous acute appendicitis after being misdiagnosed with viral gastroenteritis by his GP on two consultations (22 and 24 February 2017)…

general practiceemergency medicinediagnosticcommunication
QLD2019-12-05

Harrison, Steven Leslie

61y · Male·Coronary atherosclerosis

Steven Harrison, aged 61, died of sudden coronary atherosclerosis while incarcerated at Wolston Correctional Centre. He had multiple cardiovascular risk factors including Type 2 diabetes, heavy smoking history, and intra…

cardiologygeneral practicediagnosticsystemmetformin
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone
NSW2019-11-08

Redacted findings in the joint inquest into deaths arising at music festivals including annexures - 8 November 2019

[18, 21, 23, 19, 22, 19]y · ["male", "female", "male", "male", "male", "female"]·MDMA toxicity (one case mixed MDMA and cocaine toxicity)

This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …

emergency medicineintensive carecommunicationproceduralMDMA
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem
NSWhospital2019-10-25

Inquest into the death of Peter SMITH

67y · Male·Gas gangrene with antecedent cause of Clostridium septicum septicaemia

Peter Smith, 67, presented to Cooma Hospital with severe leg muscle cramps and pain on 6 February 2018. Despite appropriate pain management and initial investigation suggesting rhabdomyolysis, he rapidly deteriorated and…

emergency medicinegeneral practicesystemmorphine
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