Coronial

260 results for chronic anxiety

VICaged care2023-02-23

Finding into death of H D

87y · Female·Complications following a medication administration error in a woman with multip…

An 87-year-old woman died from complications of a medication administration error at an aged care facility. During transition from paper-based to electronic medication charts in December 2020, a pharmacy data entry error…

geriatric medicinegeneral practicemedicationsystemrisedronate
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …

addiction medicinegeneral practicediagnosticmedicationmethadone
QLDmental health2026-01-29

Inquest into the death of Tiesha Marie Derbyshire

18y · Female·Mixed drug toxicity

Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally overdosing on proprano…

psychiatrygeneral practicecommunicationsystempropranolol
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …

psychiatrypsychologysystemcommunicationpseudoephedrine
VIChome2025-09-02

Finding into death of Mr IKL

29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…

A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…

general practicepsychiatrydiagnosticmedicationgabapentin
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

…e child's respiratory infection progressed untreated for days, becoming fatal. Systemic failures included chronic caseworker shortages, premature case closure, delegating statutory responsibilities to non-government age…

paediatricspsychiatrydiagnosticcommunicationquetiapine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

A 32-year-old woman with Sponastrime Dysplasia (a rare genetic bone disorder) died during elective bariatric surgery. She had undiagnosed subglottic stenosis (airway narrowing) and tracheobronchomalacia. Critical clinica…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
NTcommunity2026-01-23

Inquest into the death of Kumanjayi Johnson

45y · Male·Environmental exposure and dehydration

A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and multiple medical conditions died from environmental exposure and dehydra…

geriatric medicinepsychiatrycommunicationsystem
WAAugust 2024

Inquest into the Death of Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

Matthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 month…

psychiatrypsychologysystemdelayvenlafaxine
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…

general practicesurgerycommunicationsystemdoxylamine
NSWcommunity2014-06-27

Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…

This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…

general practiceemergency medicinediagnosticmedicationalprazolam
VICcommunity2014-04-07

Finding into death of Kirk Ardern

32y · Male·Multiple drug toxicity (including heroin)

Kirk Steven Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failure…

general practiceaddiction medicinemedicationcommunicationheroin
QLD2019-05-08

Appleton, Garry Ronald

48y · Male·Hypovolaemic shock due to incised wounds to the arms; other significant conditio…

Garry Ronald Appleton, a 48-year-old Indigenous man with schizophrenia, emphysema, and coronary disease, died from hypovolaemic shock after cutting his forearms with a prison-issue razor blade while in custody at Brisban…

psychiatrypsychologycommunicationsystem
NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the chil…

general practicepsychiatrycommunicationsystemtriflouperazine
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

… order the previous day after psychiatric assessment diagnosed M with borderline personality disorder and chronic PTSD, identifying her as posing significant risk of lethal violence to herself and children. Critical cli…

psychiatrypaediatricsdiagnosticsystem
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
SAhospital2018-03-05

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…

Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…

psychiatrypsychologydiagnosticcommunicationquetiapine
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone

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