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WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
VIC2015-12-18

Finding into death of Odisseas Vekiaris

29y · Male·Unascertained causes on a background of agitated delirium state

A 29-year-old man with a 12-year history of mental illness died in police custody during transport to a police station. He had stopped taking his antipsychotic medication (Risperidone 4mg daily) following GP advice to re…

general practicepsychiatrycommunicationsystemrisperidone
NSW2015-12-18

Inquest into the death of Officer A

43y · Female·External neck compression due to self-inflicted hanging

A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…

psychiatrypsychologydiagnosticsystemprescription medication
VIChome2015-12-16

Finding into death of Andrew Stanyer

37y · Male·Hanging

Andrew Stanyer, a 37-year-old male with significant life stressors, died by hanging after police attendance at a family violence incident. He had previous suicide attempts (2000, 2009), depression treated with sertraline…

psychiatrygeneral practicesystemcommunicationsertraline
VIChospital2015-12-02

Finding into death of Justin Damien Connell

37y · Male·Multiple injuries (motor vehicle impact – pedestrian)

Justin Connell, a 37-year-old man with schizophrenia, died from multiple injuries sustained in a pedestrian–motor vehicle collision on 13 February 2013. He had been diagnosed with schizophrenia in October 2012 and prescr…

psychiatryemergency medicinecommunicationsystemaripiprazole
VIChome2015-11-30

Finding into death of Anitha Mathew, Philip , Mathew George

37, 9, 5y · Female, male, male·Effects of fire

Three deaths (mother and two young sons) resulting from a fire deliberately set by the mother. A 37-year-old educated woman from India living in Australia experienced escalating isolation, marital conflict, and lack of e…

general practicepsychiatrysystemcommunicationzolpidem
VIChome2015-11-16

Finding into death of Leanne Margaret Patterson

52y · Female·gunshot wound to head

Leanne Patterson, 52, was shot and killed by her husband Neil in a murder-suicide on 5-6 January 2013. She had been sedated with clonazepam (prescribed to her husband) and zolpidem at the time of her death. The death occ…

general practicepain medicinecommunicationsystemclonazepam
TASaged care2015-11-12

Coroner's Finding: Henri, Paul Lucien

78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…

Paul Henri, 78, died from cerebral infarction and hypoxic brain damage following aspiration pneumonia and opioid-related complications. He was admitted to an aged care home and commenced on MS Contin (morphine) 30mg dail…

general practiceneurologymedicationdiagnosticmorphine
VICmental health2015-10-30

Finding into death of Jarrod Wade Christie

23y · Male·injuries sustained when struck by train

Jarrod Christie, 23, a voluntary then involuntary psychiatric inpatient at Maroondah Hospital, absconded from the high-dependency unit on 22 December 2012 and died by suicide. Clinical lessons include: (1) GPs should ful…

psychiatrygeneral practicecommunicationsystemdesvenlafaxine
NSWhome2015-10-29

Inquest into the death of Noreen PEACOCK

83y · Female·undetermined (likely hypothermia based on clinical findings)

An 83-year-old woman with advanced Alzheimer's and vascular dementia died alone at home between April-August 2013. The coroner found the direct cause undetermined (likely hypothermia) but highlighted critical preventable…

geriatric medicinegeneral practicedelaycommunicationatorvastatin
VIChome2015-10-28

Finding into death of Hannah Rachel Charles

17y · Female·Combined drug toxicity (heroin, codeine, methadone, benzodiazepines)

Hannah Charles, a 17-year-old with substance abuse issues, died from combined drug toxicity (heroin, codeine, methadone, benzodiazepines) at a private residence where she had been staying with two opioid replacement ther…

addiction medicineforensic medicinediagnosticsystemheroin
NSWhome2015-10-23

Inquest into the death of Christine Drinnan

45y · Female·Multi-drug toxicity

Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …

general practicepsychiatrydiagnosticmedicationmorphine
NSWhome2015-10-23

Inquest into the death of Scott Clements

36y · Male·Unknown - advanced decomposition precluded determination

Scott Clements, a 36-year-old man with longstanding mental illness, depression, substance use disorder and multiple suicide attempts, was found dead at his home between 19 August and 14 October 2014. His body was in adva…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VIChospital2015-10-19

Finding into death of Daniella Francesca Sessarego

24y · Female·Pentobarbitone toxicity

24-year-old Daniella Sessarego died from pentobarbitone toxicity following intentional ingestion. She had borderline personality disorder and depression with a history of self-harm and suicidality. On 12 August 2014, she…

psychiatrypsychologysystempentobarbitone
VICmental health2015-10-15

Finding into death of Helen Maria Bryce

54y · Female·Hanging

A 54-year-old woman with a history of puerperal psychosis presented with severe depression and anxiety in early 2011. After two suicide attempts, she was admitted to Austin Health's Acute Psychiatric Unit involuntarily. …

psychiatrygeneral practicecommunicationsystemcitalopram
VIC2015-10-05

Finding into death of Catherine Jane Bernard

17y · Female·multiple injuries due to impact by train

A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clin…

emergency medicinepsychiatrycommunicationsystemtemazepam
TAShome2015-10-02

Coroner's Finding: Ms G de-identified

Female·hanging (suicide)

Ms G, a woman in her forties with bipolar II disorder, generalised anxiety disorder, and severe alcohol dependence, died by suicide in November 2014. She had been admitted to hospital six times for detoxification and men…

psychiatryaddiction medicinesystemalcohol
VIChospital2015-09-27

Finding into death of Peter Heng Dowe Chiam

77y · Male·Cerebral infarction (stroke) complicating elective hernia repair

A 77-year-old man with atrial fibrillation on warfarin underwent elective hernia repair. Warfarin was appropriately ceased five days pre-operatively. Post-operatively, warfarin was recommenced on day 1 post-op at 5pm. He…

cardiothoracic surgeryanaesthesiacommunicationsystemwarfarin
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