VIC2022-08-05
Finding into death of Y GE
Male·Hanging
YGE, a man with major depressive disorder, suicidality, and illicit substance use, died by hanging at the Neighbourhood Justice Centre on 28 Decemb…
psychiatrygeneral practiceheroin
29 results for “substance use disorder (perpetrator)”
VIChome2017-02-17
Finding into death of James Peter Berias
34y · Male·Stab wound to the chest
…he context of a turbulent relationship characterised by mutual physical violence, recent separation, and substance abuse (methylamphetamine use by both parties). The partner had escalating mental health concerns with pa…
general practicepsychiatrymethamphetamine
VIChome2016-04-04
Finding into death of Jacinta Pompei
32y · Female·Blunt force trauma to the head
…t. Although Mr Ellard displayed some early warning signs of deterioration in the two weeks prior and had substance use issues, minimal typical early warning signs were evident. The coroner confirmed no further investiga…
psychiatryforensic medicineclozapine
VIC2018-11-07
Finding into death of Paul Francis O'Donnell
48y · Male·Stab wound to the hip causing exsanguination from incision of the external iliac…
…ances about being excluded from family due to alleged accusations of sexual assault. Lamblin had planned to use a borrowed guitar as a conversation opener about their relationship. He arrived at the factory armed with a…
methamphetamine
VIChome2026-03-20
Finding into death of HD S
41y · Female·Multiple injuries from assault
…s; and adult safeguarding legislation is needed to coordinate responses to vulnerable adults experiencing abuse. Police missed opportunities to include the victim's child on protection orders, ensure proper referrals to…
communicationsystemcannabis
VIC2019-02-13
Finding into death of Gordon Harvey
62y · Male·Blunt force trauma to the head
…nadequate for non-heterosexual relationships; (3) the substantial vulnerability of victims with comorbid substance misuse and mental health conditions; and (4) failures by Corrections Victoria to manage Mr Kepenci despi…
forensic medicinetoxicologycommunicationsystemmirtazapine
VIChome2025-05-20
Finding into death of CDE
33y · Female·Sharp force neck and chest injuries
…reated mental health conditions. The perpetrator had a history of schizophrenia, anxiety, depression and substance abuse. Prior incidents in January 2018 involved severe physical assaults but were inadequately prosecute…
psychiatryemergency medicinesystemcommunicationsynthetic marijuana
VIChome2025-08-07
Finding into death of DCF
59y · Male·Multiple stab injuries
A 59-year-old man was fatally stabbed by his former partner in a context of longstanding family violence. The deceased had perpetrated significant violence against the perpetrator, who had mental illness and housing inst…
psychiatryemergency medicinecommunicationsystemmethamphetamine
VICcommunity2018-04-09
Finding into death of Benjamin Gleeson
37y · Male·Carbon monoxide poisoning
…ear-old man, died from carbon monoxide poisoning by exhaust inhalation. He had a history of methamphetamine use, depression with suicidal ideation, and was a perpetrator of family violence. Despite receiving mental heal…
psychiatrygeneral practicesystemmethamphetamine
VIChome2025-09-11
Finding into death of ZSQ
26y · Female·Multiple stab wounds
ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…
emergency medicinepsychiatrycommunicationsystemcocaine
VIChome2025-02-27
Finding into death of Shayn Nathan Darmanin
43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…
…involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence offending, and mental health issues. His death was the unintended consequence of …
toxicologypsychiatrymethadone
VIChome2025-08-28
Finding into death of MJU & KJH
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
…H once. Despite MJU calling emergency services at 12:40pm reporting CTH's hallucinations, paranoia and drug use, paramedics and police assessed him as not meeting Mental Health Act thresholds for involuntary admission. …
psychiatryemergency medicinediagnosticcommunicationmethamphetamine
VIChome2025-10-09
Finding into death of Narelle Catherine Simmons
42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…
…mate partner Craig Jennion between 10-19 October 2021. Clinical lessons: victims of family violence with substance use disorders are at heightened risk of femicide and may present with injuries initially misattributed t…
forensic medicinegeneral practicediagnosticcommunicationmethadone
QLDhome2016-05-03
Tauati, Tui Dace - Non-inquest findings
21y · Male·hanging
…receding months. Despite identified high-risk factors for suicide (young male in post-separation period, substance use, relationship distress, possible depression), no systemic failures in suicide prevention were identi…
systemmethamphetamine
QLDhome2024-07-22
Non-inquest findings into the domestic violence related death of a First Nations woman
31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…
A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…
general practiceobstetricscommunicationsystemmethamphetamine
VIChome2025-01-31
Finding into death of FCP
45y · Female·Drowning whilst inebriated (ethanol)
…more East, Victoria. She had a complex history of mental illness (psychosis, depression, anxiety, PTSD), substance abuse, and was in a relationship with controlling and abusive dynamics. Following a deterioration in men…
psychiatryemergency medicinesystemcommunicationalcohol
VIChome2018-11-07
Finding into death of Abuk Derder Akek
19y · Female·Stab wounds to the abdomen
…ve family violence risk assessment frameworks, mandatory family violence education for mental health and substance use workers, appointment of specialist family violence advisors in major services, and culturally approp…
psychiatrygeneral practicediagnosticsystem
VICcommunity2012-12-10
Finding into death of Lynette May Phillips
27y · Female·neck compression
27-year-old Lynette Phillips died from neck compression (strangulation) at the hands of her intimate partner Benjamin Pappas in February 2007. Lynette had a documented history of family violence, drug dependency, and was…
general practicepsychiatrycommunicationsystemheroin
VICcommunity2020-05-11
Finding into death of Jolanta Boyd
48y · Female·Multiple injuries sustained when struck by a train
…nta Boyd, a 48-year-old woman with documented mental health conditions including suicidal ideation, alcohol use disorder, and anxiety, died by suicide on 18 June 2018 when she jumped in front of a train at Windsor railw…
psychiatryemergency medicinecommunicationsystemalcohol
NTcommunity2016-03-09
Inquest into the death of Ronald Donaldson
69y · Male·Blunt head trauma
Ronald Donaldson, a 69-year-old fencing contractor, was killed by Justin Osborne with a sledgehammer in Katherine on 3 December 2013. Osborne was experiencing untreated schizophrenia with acute psychotic symptoms and bel…
psychiatryemergency medicinedelaymarijuana
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.