Coronial

318 results for substance use (cannabis)

NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

…firearm from Correctional Services Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predicament. The c…

psychiatrycorrectional healthsystemcommunicationmethadone
ACTmental health2015-06-15

AN INQUEST INTO THE DEATH OF PETER ZOVAK

46y · Male·asphyxia by hanging

Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After in…

psychiatryemergency medicinediagnosticcommunicationcannabis
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
VIChome2022-10-06

Finding into death of Dannyll Ann Goodsell

33y · Female·Incised injuries to the neck

Dannyll Ann Goodsell, 33 years old, was murdered by her intimate partner Scott Cameron through multiple incised injuries to the neck causing exsanguination. Ms Goodsell had disclosed to friends that she was scared of Mr …

forensic medicinepsychiatrycommunicationsystemmethamphetamine
NTcommunity2020-12-15

Inquest into the death of Master W, Miss B and Master JK

volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…

…est examines three children (Master W aged 12, Miss B aged 17, Master JK aged 13) who died from volatile substance abuse in remote Aboriginal communities in the NT between 2018-2019. All three were known to government a…

psychiatryaddiction medicinediagnosticsystempetrol
NSW2016-09-12

Inquest into the death of M

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

…d from accidental overdose of heroin and methylamphetamine (speedballing) in her bedroom while a known drug user was present. She had complex trauma from childhood abuse, a history of drug use and absconding, and was aw…

emergency medicinetoxicologydelaysystemheroin
SAhome2009-06-04

Coroner's Finding: PROBY Zak Dean

27y · Male·combined effects of penetrating injuries (crossbow arrows) to heart and brain

…e and Mr Proby's lucid presentation. The following day, he threatened his GP with a crossbow after being refused referral to psychology services. A police siege ensued with appropriate negotiation attempts before he set…

emergency medicinegeneral practicecommunicationmarijuana
NSW2022-10-12

Inquest into the death of ZH

29y · Male·Hanging

ZH, a 29-year-old man serving a 9-year sentence for drug supply, died by hanging in his minimum-security cell at Parklea Correctional Centre on 11 August 2021. The coroner found his death was self-inflicted. Key clinical…

psychiatrygeneral practicecommunicationsystemmethamphetamine
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

… months in each case), inadequate risk assessment despite identified high-risk factors (family violence, substance use, mental health issues, parental inability to care for other children), failure to provide safe sleep…

paediatricspsychiatrydiagnosticcommunicationmethadone
NSWhome2025-06-24

Inquest into the death of Jade

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

…tal mental health issues. Brighter Futures' practitioner, despite observing concerning signs of parental substance use and suspected violence in March 2018, did not make a mandatory report due to misplaced concerns abou…

paediatricspsychiatrydiagnosticcommunicationquetiapine
TAShome2018-11-16

Coroner's Finding: Taylor, Michael John

50y · Male·methadone and alprazolam intoxication

…hing and injecting his prescribed methadone tablets, a practice inherently dangerous due to pill binding substances causing lung and vascular damage. He was found unresponsive at home approximately 1.5 hours after becom…

general practicepain medicinecommunicationsystemmethadone
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

…intoxicated by intravenous morphine and methamphetamine, remained nearby. The autopsy revealed no obvious cause, but documented face-down positioning, respiratory infection, passive smoking exposure, and unsafe sleep en…

paediatricsforensic medicinesystemdelaymorphine
VICcommunity2025-04-17

Finding into death of Abdul El Sayed

Unknown·Toxicity to protonitazene

Four people died from protonitazene toxicity on 24 June 2024 after inhaling what they believed was cocaine but which was adulterated with protonitazene, an extremely potent synthetic opioid (100 times more potent than he…

toxicologyforensic medicineprotonitazene
SAhospital2018-07-19

Coroner's Finding: ROSS Chrystal Jessica

24y · Female·hypoxic brain injury secondary to hanging

…es and care coordination errors. She had been admitted to Mount Barker Hospital for anxiety, depression, substance misuse concerns, and self-harm behaviours. After one week, a psychiatrist recommended admission to a spe…

psychiatrygeneral practicecommunicationdiagnosticfluvoxamine
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
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

…Lock to specialist domestic violence support services despite her explicit disclosure of intimate partner abuse; a general practitioner treating both victim and perpetrator concurrently without formal risk assessment or…

general practicepsychiatrydiagnosticcommunicationcannabis
SA2024-12-20

Coroner's Finding: Huddy, Kobee Michael David

20y · Male·gunshot wound to the chest

…mental health services and Lifeline that morning expressing suicidal ideation, then left his girlfriend's house believing he was getting cigarettes. Police followed and stopped the vehicle he was in; he exited with a la…

psychiatryemergency medicinecommunicationsystemcannabis
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 fo…

psychiatrytoxicologycommunicationdelaymethamphetamine
QLD2017-10-20

Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster

Male·Police use of lethal force; coroner found in each case the officers acted approp…

This multi-death inquest examined five police shootings in Queensland (2013-2014) where all deceased had mental health histories. The coroner found officers acted appropriately in each case but made 19 recommendations to…

emergency medicinepsychiatrysystemcommunicationmethamphetamine
SA2017-02-17

Coroner's Finding: MCPHERSON Lewis Mike

18y · Male·Gunshot wound to chest

…eventable. Humbles had illegally possessed a handgun for months, dealt drugs, and was deeply troubled by substance abuse. Police received multiple credible reports of the firearm in June and July 2012 but failed to act …

communicationsystemcannabis
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