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SAhospital2005-06-02

Coroner's Finding: GREEN Marie

64y · Female·Respiratory arrest secondary to morphine overdosage on a background of mild to m…

A 64-year-old woman died from respiratory arrest secondary to morphine overdose after ingesting 17 tablets of slow-release morphine (Kapanol) and diazepam. Initial emergency assessment by an intern was appropriate, but c…

emergency medicinegeneral medicinecommunicationdiagnosticmorphine
SAprison2005-05-31

Coroner's Finding: McLEOD Ian

45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage

Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody at Yatala Labour Prison. Multiple system failures contribu…

psychiatrycorrectional healthdiagnosticcommunicationdiazepam
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …

psychiatryemergency medicinediagnosticmedicationvecuronium
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

Peta Dawson, a 26-year-old woman with a history of depression, self-harm, and suicidal ideation following miscarriage and maternal rejection, was admitted to Merredin Hospital on 10 August 2003 after presenting with wris…

emergency medicinepsychiatrysystemdelaykalma
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …

psychiatryemergency medicinecommunicationsystemolanzapine
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
SAcommunity2005-03-14

Coroner's Finding: Ryan Kunmanara

Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…

Four Aboriginal individuals died on Anangu Pitjantjatjara Lands between May 2003 and March 2004. Ward (19) and Ryan (25) died by hanging with evidence of petrol intoxication. Ken (35) died from exposure after wandering a…

psychiatryemergency medicinedelaysystempetrol
SAcommunity2005-03-14

Coroner's Finding: Cooper Kunmanara

Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…

Four separate inquests into the deaths of Kunmanara Ward (19), Kunmanara Ken (35), Kunmanara Ryan (25), and Kunmanara Cooper (27) on the Anangu Pitjantjatjara Lands between May 2003 and March 2004. Three deaths were by h…

psychiatrygeneral practicedelaycommunicationpetrol
SA2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…

This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…

psychiatryemergency medicinecommunicationsystempetrol
NThospital2005-02-07

Inquest into the death of William Bunting

46y · Male·self-inflicted hanging

William Mark Bunting, a 46-year-old man with depression and alcoholism, died by hanging in Alice Springs Hospital on 15 December 2003 while a voluntary mental health patient. He had been admitted for the second time on 5…

psychiatrysystemcitalopram
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

Hendrik Jan Groothedde, a 39-year-old remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girl…

psychiatrycorrectional healthcommunicationsystemantidepressants
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

Damien George Garlett, an 18-year-old Aboriginal remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 4 April 2003. He had a history of self-harm, drug-induced psychosis, violent offence…

psychiatrypsychologydiagnosticcommunication
SAhome2004-11-18

Coroner's Finding: CUNNINGHAM Tracey-Lee

26y · Female·morphine toxicity complicated terminally by bronchopneumonia

A 26-year-old woman with chronic migraines and depression died from morphine toxicity complicated by aspiration pneumonia. She had a documented history of drug-seeking behaviour, forged prescriptions, and doctor-shopping…

general practiceneurologymedicationdiagnosticmorphine
WAhospital2004-11-12

Inquest into the Death of Mortensen

60y · Female·Aspiration of food in a woman with cerebral atrophy

Jytte Mortensen, a 60-year-old woman with multi-infarct dementia and schizoaffective disorder, died at Graylands Hospital from aspiration of food. She had documented dysphagia requiring a pureed diet and one-to-one super…

psychiatryspeech pathologycommunicationsystem
QLDcommunity2004-10-28

Cif Shoobridge Gr 20041028

25y · Male·Cardiorespiratory failure due to unpredictable additive effect of combination of…

George Shoobridge, a 25-year-old man with a long history of polydrug addiction, died from cardiorespiratory failure caused by the unpredictable additive effect of multiple drugs in combination (diazepam, morphine, codein…

general practiceaddiction medicinecommunicationsystemdiazepam
WAhome2004-10-28

Inquest into the Death of Kelly

33y · Female·Combined drug toxicity, with thioridazine as the principal component, in the con…

Lou Ann Kelly, aged 33, died on 3 April 2003 at Royal Perth Hospital ICU from combined drug toxicity, primarily thioridazine, after consuming large quantities of prescription medications with alcohol. She collapsed at he…

general practicepsychiatrysystemthioridazine
QLDmental health2004-09-30

Cif Lee Ja 20040930

23y · Male·compression of the neck, secondary to coronary arteriosclerosis

Julian Arasina Lee, a 23-year-old man, died on 1 February 2003 during a restraint incident in the Mental Health Unit at Cairns Base Hospital. Admitted voluntarily after exhibiting marked behavioral changes, he became inc…

psychiatryemergency medicineproceduralcommunicationdroperidol
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, mul…

psychiatryemergency medicinediagnosticsystemcannabis
WAmental health2004-09

Inquest into the Death of Peter Daniel Mahoney

55y · Male·Immersion (Drowning) arising by way of suicide

Peter Daniel Mahoney, a 55-year-old man with treatment-resistant bipolar affective disorder, died by drowning on 13 June 2003 after absconding from Joondalup Health Campus where he was detained as an involuntary patient …

psychiatrypsychiatrycommunicationsystemtemazepam
SA2004-08-06

Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…

psychiatryemergency medicineproceduralsystemfluvoxamine
177787983

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