Coronial
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NSWcommunity2017-06-16

Inquest into the disappearance and suspected death of Thanagarajah SITHAMPARAPILLAI

62y · Male·undetermined

…Coogee, most likely in or near water. Mr Sithamparapillai had recently lost his job and was experiencing depression, psychological distress, and fleeting thoughts of self-harm. He had consulted his GP and a psychiatrist …

general practicepsychiatrydosulepin
VIChospital2015-12-09

Finding into death of Benjamin David Johnston

36y · Male·Global hypoxic brain injury due to hanging

…gnificant behavioral changes: withdrawal, irritability, anger, and sleep difficulty. He had a history of depression in 2010 but was assessed as depression-free before varenicline prescription. On the day of death, he had…

general practicepsychiatryvarenicline
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

…-up, despite clinical guidelines recommending this. Families received no education about the 33% risk of depression in stroke survivors generally, or the 60% risk in those with aphasia specifically, and were not informed…

neurologyrehabilitation medicinediagnosticsystem
SAhospital2014-11-28

Coroner's Finding: BLAIN Kathleen Olive Florence

79y · Female·acute myocardial infarction and acute pulmonary oedema

… woman with stroke and cardiac history was admitted for rehabilitation but developed treatment-resistant depression. Despite comprehensive multidisciplinary management including medication trials (mirtazapine, citalopram…

psychiatrycardiologymirtazapine
SAhospital2018-07-27

Coroner's Finding: CUTTS Charles Desmond

70y · Male·aspiration pneumonia due to seizures

70-year-old man with insulin-dependent diabetes, cognitive impairment, depression, alcohol abuse history, and seizure disorder died from aspiration pneumonia following seizures while adm…

emergency medicinepsychiatryrisperidone
TAShome2022-11-30

Coroner's Finding: Donnelly, Christopher Ronald

68y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)

…ew regimen with only 2 seizures in the 3 months prior to death. He also had vascular dementia, COPD, and depression. A family member raised concerns about prescribing Keppra given his mental health issues and dementia, b…

neurologygeneral practicelevetiracetam
VIChospital2016-10-04

Finding into death of Damien Marius Van Der Korput

50y · Male·Hypoxic ischaemic brain injury in the context of hanging

A 50-year-old man with longstanding depression, anxiety, and ADHD died by hanging after an acute deterioration in mental state. He had previous psychia…

psychiatryemergency medicinecommunicationsystemalcohol
VIChome2017-06-21

Finding into death of Mrs DA

59y · Female·Multiple drug toxicity (propoxyphene, citalopram, oxazepam and others)

…had suffered a severe stroke in 2006 with resultant significant disability, chronic pain, and subsequent depression with suicidal ideation. Despite psychiatric involvement and GP care, she remained resistant to supportiv…

rehabilitation medicinegeneral practicepropoxyphene
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…

…ns despite new sedating medications. Combination morphine with quetiapine likely exacerbated respiratory depression. The patient rapidly deteriorated with hypoxia, hypotension, and altered consciousness. While opioid tox…

general practiceneurologymedicationdiagnosticmorphine
NSWhospital2015-10-28

Inquest into the death of Michael NELSON

62y · Male·multiple co-morbidities including dementia, Parkinson's disease, undernourishmen…

…and RN Louise Copeland. Although the dose was within recommended limits, Mr Nelson developed respiratory depression and initial respiratory arrest, though he resumed breathing after CPR was ceased. He died approximately …

emergency medicineneurologymedicationcommunicationmidazolam
VIChome2024-12-16

Finding into death of Geoffrey Paul McConachy

82y · Male·Incised injury to right leg

…by suicide on 18 September 2023 following a stroke in late 2022 that caused speech impairment and severe depression. He explicitly expressed suicidal ideation and requested information about voluntary assisted dying (VAD…

psychiatrygeneral practicecitalopram
VIChome2011-08-16

Finding into death of Luciano T

75y · Male·Gunshot wound to the head

Luciano T, a 75-year-old man with complex medical and psychiatric history including chronic pain, depression, and delusional jealousy syndrome, shot his wife in the face and then fatally shot himself. He had been …

psychiatryneurologyoxazepam
VIChospital2014-12-04

Finding into death of Anastasios Kosmas

60y · Male·Ischaemic cerebrovascular accident

Anastasios Kosmas, 60-year-old male with psychiatric history (manic schizophrenia, depression) and cardiovascular risk factors (diabetes, hypertension, hyperlipidaemia), collapsed on 19 May 2013 at …

neurologypsychiatry
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

…nformation; failure to recognise clinical deterioration despite clear family observations of respiratory depression and profound drowsiness; and prescription of slow-release oxycodone (OxyContin) in combination with fast…

neurologyemergency medicinediagnosticmedicationfentanyl
SAhospital2025-07-03

Coroner's Finding: Provis, Adam James

50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…

A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and athero…

psychiatryneurologythiamine
WAhome2013

Inquest into the Death of Stevens, Malachi Isaac and Stevens, Lochlan James

10y · Male·Unascertainable

Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…

paediatricsforensic medicinesystemdelay
VICcommunity2010-01-14

Finding into death of Joeanne Maree Brady

39y · Female·Mixed drug toxicity (methadone, oxycodone, hydromorphone, mirtazapine, diazepam,…

…ntinued taking oxycontin while starting methadone, resulting in combined opioid toxicity and respiratory depression leading to death four days later. Key failures: inadequate explanation of medication change, no written …

pain medicineneurologycommunicationmedicationmethadone
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was presc…

general practiceneurologymedicationcommunicationfentanyl
VIChome2025-03-12

Finding into death of H D

11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…

…h severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August 2023 after a 12-month period o…

paediatricspalliative care
VIChospital2010-03-24

Coroner's Finding: Janet Carol Rosse

32y · Female·Mexiletine toxicity

…gical condition causing recurring paralytic episodes and chronic pain, and a concurrent history of major depression and anxiety. In August 2007, she was admitted to St Vincent's Hospital with generalised weakness. The ne…

neurologypsychiatrycommunicationsystemmexiletine

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