213 results for “medication dependence”
36y · Female·Mixed drug toxicity
Skye Turner, a 36-year-old woman with borderline personality disorder and substance use disorder, died from mixed drug toxicity after being discharged from Maroondah Hospital on 8 March 2017. She had been admitted with o…
40y · Male·Ligature compression of the neck in circumstances of being hanged
…mal directives prioritising rapid throughput; critical clinical information (prior ITO, suicide threats, medication history) was not made available to reviewing staff; and the focus on brief assessments prevented longitu…
40y · Male·Gunshot wound to neck
…amphetamine by psychiatrist Dr F., continuing under GP Dr S.'s care. His mother expressed concerns about medication-related behavioural changes in March 2019, prompting referral to a specialist who was unavailable. Dr S.…
41y · Female·unable to determine
…Hospital on 1-2 November 2017 with acute psychosis related to schizophrenia, having ceased antipsychotic medication and methadone. The mental health and emergency departments disagreed over her care—mental health would n…
24y · Female·Undetermined
Monique Irene Clubb, a 24-year-old with opioid addiction following a serious motor vehicle accident, disappeared on 22 June 2013 after obtaining prescriptions for fentanyl patches and diazepam from a medical centre in Be…
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…
34y · Female·complications of metastatic rectal cancer
… with the deceased (over 100 consultations), convinced her that pain was psychological, discouraged pain medication, and even advised against emergency surgery in October 2003. By the time emergency surgery was performed…
35y · Male·Unascertained, following autopsy. Likely drowning but circumstances undetermined…
A 35-year-old man with chronic alcohol dependence was admitted to the ED with acute alcohol withdrawal and auditory hallucinations. Despite presenting wit…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
…er court case, which the team knew was a major stressor; and failure to provide transport home or verify medication access. The coroner found deficiencies in care and assessment.
40y · Female·Injuries sustained when struck by a train (in circumstances where the deceased i…
…ea (2018-2019) and commissioned investigation into vulnerabilities including social isolation, financial dependence, family violence, language barriers, and lack of culturally appropriate mental health services. The case…
24y · Male·Neck compression in the circumstances of hanging
…trict Aboriginal Services (MDAS), which provided appropriate community-based care including counselling, medication, and practical support. However, documented suicide risk assessments were not evident in his clinical re…
35y · Male·Gunshot wound to the head (self-inflicted)
Daniel Thomas, aged 35, died from a self-inflicted gunshot wound during a police siege. He had a history of substance-induced psychosis from ice use, with multiple psychiatric admissions in 2015-2016. Following discharge…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
…besity, type 2 diabetes, undiagnosed obstructive sleep apnoea) and was prescribed multiple QT-prolonging medications (methadone, mirtazapine, amitriptyline, duloxetine, baclofen). The coroner identified multiple systemic…
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
Multiple: pneumonia with cardiomyopathy (Kugena female); septic shock from pneum…
Concurrent coronial inquests into six Aboriginal deaths in Ceduna, South Australia between 2004-2009. All deceased had severe alcohol addiction and comorbidities including pneumonia, cardiomyopathy, liver disease, and se…
37y · Male·Pulmonary thromboembolus due to left leg deep vein thrombosis
A 37-year-old Aboriginal man died of pulmonary thromboembolism due to deep vein thrombosis while incarcerated. He presented to hospital on his birthday with lethargy, shortness of breath, and tachycardia. Initial assessm…
16y · Female·respiratory arrest caused by combined toxic effects of methadone and alprazolam
This is a coronial prevention report examining methadone takeaway dosing risks in Victoria, prepared following the death of Helen Stagoll (age 16) in 2010 from respiratory arrest caused by diverted methadone and alprazol…
25y · Female·Chest injuries due to fall from height
…inical deterioration postpartum. AW spent 462 days in an unsuitable acute ward, developed severe alcohol dependence unchecked by behavioural management, and died on the day of a Mental Health Review Tribunal hearing. Key…
60y · Female·neck compression by ligature strangulation
Martina Morgan, aged 60, died from ligature strangulation by her own leggings while in police custody at Sturt Police Station in March 2015. She was significantly intoxicated (BAC 0.23%) and taking benzodiazepines when a…
54y · Female·mixed drug toxicity (methadone and diazepam)
A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…
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