Coronial

568 results for overdose

VIChome2025-02-07

Finding into death of T

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), …

paediatricspsychiatrycommunicationsystemheroin
NSW2016-09-12

Inquest into the death of M

15y · Female·hypoxic brain damage due to multiple drug toxicity

A 15-year-old girl in out-of-home residential care died from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She ha…

emergency medicinetoxicologydelaysystemheroin
QLDhospital2018-09-26

Mann, Renae Jean

43y · Female·acute toxic effects of amitriptyline

…ear-old woman with depression was admitted to Gold Coast University Hospital with suspected amitriptyline overdose. After 11 hours of ED monitoring, she was medically cleared and transferred to a mental health assessment…

emergency medicinepsychiatrydiagnosticcommunicationamitriptyline
VICcommunity2013-06-05

Finding into death of Helen Maree Stagoll

16y · Female·respiratory arrest caused by combined toxic effects of methadone and alprazolam

…s. Key clinical lessons include the tension between community integration benefits of takeaway dosing and overdose risks; the inadequacy of relying on client self-report for safety assessment; and the need for better dat…

addiction medicinepharmacologysystemdelaymethadone
NSWhospital2023-09-11

Inquest into the death of TE

26y · Female·multiple blunt force injuries from fall from height; significant contributing co…

… day. Expert evidence indicates she should have been involuntarily detained overnight to allow medication overdose effects to clear and permit comprehensive discharge planning, though three experienced psychiatrists agre…

psychiatryemergency medicinediagnosticcommunicationpregabalin
QLDhospital2012-08-13

Krog, Shane Paul

55y · Male·Morphine toxicity, with contributing factors of ischemic heart disease, coronary…

…nd rhabdomyolysis. He presented to Murgon Hospital (a 15-bed rural facility) following suspected narcotic overdose after ingesting his wife's MS Contin tablets. Key clinical failures included: Dr L.'s delayed attendance …

emergency medicinegeneral practicediagnosticdelaymorphine
VIChospital2023-08-25

Finding into death of Mr P

26y · Male·Brain death post mixed drug toxicity including MDMA and cocaine

…250-477mg MDMA, versus typical recreational doses of 100mg), which significantly contributed to his fatal overdose. The coroner recommended implementation of a drug checking service in Victoria to enable harm reduction, …

emergency medicineintensive careMDMA
SA2019-06-07

Coroner's Finding: AZAPARTI Wyatt William

45y · Male·mixed drug toxicity (methadone and pregabalin) with possible contributing factor…

A 45-year-old man died in prison from mixed drug toxicity involving methadone and pregabalin, with possible contribution from morbid obesity. He had a history of opioid use and chronic pain from a foot injury. Despite re…

correctional healthpain medicinemethadone
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

… Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' premises. Neither had been identified as at-risk by Department for Correctio…

general practicepsychiatrycommunicationdelaytramadol
NSW2022-11-08

Inquest into the death of Andrew Gilbertson

42y · Male·methadone toxicity

…jections as standard opioid substitution therapy in January 2020, preventing diversion and reducing fatal overdose risk.

forensic medicinepsychiatrysystemdelaymethadone
QLDhome2016-08-22

SJM - Non-inquest findings

57y · Male·Mixed drug toxicity, predominantly propoxyphene (Doloxene)

…ultiple central nervous system depressants (Temazepam, Alprazolam) concurrently, significantly increasing overdose risk. The GP prescribed large quantities (100 capsules at a time) without adequate monitoring, despite th…

general practicepathologymedicationdiagnosticpropoxyphene
NSWcommunity2016-05-10

Inquest into the disappearance and suspected death of Eric WARBURTON

26y · Male·Unknown

… but the cause and manner remain unknown. While there are unconfirmed accounts suggesting possible heroin overdose with body disposal, or potentially foul play, none could be verified. The investigation was significantly…

delaysystemheroin
ACThome2020-12-10

Inquest into death of KAITLIN O’KEEFE McGILL

34y · Female·morphine toxicity (morphine probably ingested as heroin), accidental death

…34-year-old woman subject to a Psychiatric Treatment Order died from morphine toxicity (accidental heroin overdose). While no deficiency in clinical care was identified, the coroner highlighted a critical gap in informat…

psychiatrycommunicationsystemmorphine
VIChome2024-03-18

Finding into death of C J

44y · Female·Mixed drug toxicity (buprenorphine, ketamine, diazepam, fluvoxamine and lacosami…

…etamine use, likely obtained from her veterinary workplace. The coroner determined this was an accidental overdose. Clinical lessons include: veterinarians have high-risk access to addictive drugs; addiction specialists …

addiction medicinepsychiatrybuprenorphine
NSW2017-07-25

Inquest into the death of Paigh Bartholomew

21y · Female·mixed heroin and alprazolam toxicity

… night of drug delivery, missing evidence of a compromised window. Inmates who witnessed Paigh's apparent overdose were intimidated from seeking help via the duress alarm. Clinical lessons include the importance of insti…

systemcommunicationheroin
VIChospital2013-09-10

Finding into death of Paul Gary Larman

28y · Male·Overdose of Clozapine

A 28-year-old man with schizophrenia and substance abuse history died from clozapine overdose. Key clinical failures included: inadequate assessment of suicide risk when prescribing one month's suppl…

psychiatryemergency medicinediagnosticmedicationclozapine
TAShome2023-05-01

Coroner's Finding: Koeter, Jacqueline Francis

59y · Female·Global hypoxic brain injury due to mixed drug toxicity, specifically alprazolam …

A 59-year-old woman with a 30-year history of alprazolam dependence for anxiety disorder died from global hypoxic brain injury following cardiac arrest caused by mixed drug toxicity, with alprazolam levels in the fatal r…

general practicepsychiatryalprazolam
NSWhospital2017-09-08

Inquest into the death of James BARTON

21y · Male·external neck compression due to hanging; intentional self-harm

…was appropriately assessed and admitted as a mentally disordered person on 3 March following a deliberate overdose of 30 ecstasy and 5 Xanax tablets. Dr N. discharged him on 4 March. On 23 March, following another acute …

psychiatrytoxicologysystemcommunicationalprazolam
NSWaged care2014-03-14

Inquest into the death of Sybil ZIMMERMAN

84y · Female·coronary artery thrombosis on a background of multiple co-morbidities including …

…, dementia, pneumonia) died of coronary artery thrombosis at hospital. The family alleged she was fatally overdosed with morphine by nursing home staff and that records were falsified. The coroner found the allegations u…

geriatric medicinegeneral practicemorphine
VICcommunity2024-11-15

Finding into death of Benjamin James Ralston

31y · Male·Mixed alcohol and drug toxicity (heroin, promethazine, benzodiazepines, 3-fluoro…

Benjamin Ralston, 31-year-old, died from mixed alcohol and drug toxicity involving heroin, promethazine, benzodiazepines, and 3-fluoromethamphetamine (3-FA). He was found unresponsive on a street after socialising and dr…

heroin
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