Coronial

368 results for substance use disorder history

NSW2021-12-09

Inquest into the death of Yohan WEPITIYA-GAMAGE

19y · Male·Hanging

Yohan Wepitiya-Gamage, a 19-year-old male remand prisoner with a history of psychosis and substance use, died by hanging in his cell at the Metropolitan Special Programs Centre i…

psychiatryemergency medicineadministrativecommunicationrisperidone
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Cen…

psychiatryemergency medicinediagnosticcommunicationalcohol
VIChome2021-02-24

Finding into death of AAC

29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…

…ing pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting approximately 60 general practitioners and using false identities to obtain medi…

general practicetoxicologydiagnosticsystempregabalin
NSWcommunity2026-05-19

Inquest into the death of Dion White-Cotterell

45y · Male·Multiple stab wounds

…(83 wounds) on 28 February 2019 by his neighbour Benjamin Moore in an unprovoked attack outside their townhouse in Parramatta. Moore, suffering acute schizophrenia relapse with a long history of violence and substance a…

psychiatrysystemcommunication
VICmental health2014-11-17

Finding into death of Justin Peter Foster

40y · Male·unascertained

Justin Foster, a 40-year-old man with bipolar affective disorder, chronic back pain, and substance abuse history, died suddenly in a psychiatric inpatient unit (Upton Hou…

psychiatryforensic medicinecommunicationdiazepam
VICcommunity2025-09-05

Finding into death of Lisa Nicole Murphy

52y · Female·unascertained - likely combination of underlying natural disease (myocardial inf…

Lisa Murphy, a 52-year-old woman with mental illness and substance use history, died following a physical altercation at a convenience store. She became involved in a verb…

emergency medicineintensive carecommunicationrisperidone
VIChome2018-08-06

Finding into death of Samuel Jack Morrison

24y · Male·Combined drug toxicity (heroin, benzodiazepine and others)

Samuel Morrison, 24, died from combined drug toxicity involving heroin, benzodiazepines and other substances. He had a long history of depression, anxiety and illicit drug use, and had recently been discharged fr…

psychiatrygeneral practicesystemdelayheroin
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…

…nadequate communication between GPs and pharmacists; prescribing of benzodiazepines and opioids to known substance-dependent patients; failure to consult psychiatrists for long-term psychiatric medication; emergency dep…

general practiceemergency medicinediagnosticmedicationalprazolam
VIC2016-04-14

Finding into death of Oscar Nicholas McIntyre

17y · Male·injuries sustained in a motorcycle incident (driver)

… Island, rode across the infield at full speed without braking, and was struck by another rider. He had a history of mental health issues treated with antidepressants and anxiety medication. Post-mortem toxicology detec…

psychiatrygeneral practicemethamphetamine
VIChome2025-08-07

Finding into death of DCF

59y · Male·Multiple stab injuries

…ce due to focus on the perpetrator's FVIO breach and a LEAP database outage preventing access to violence history. The coroner identified concerns about police misidentification of the predominant aggressor in family vi…

psychiatryemergency medicinecommunicationsystemmethamphetamine
WAhome2025-01-23

Inquest into the Suspected Death of Benjamin Jacob VAN TRIGT

38y · Male·electrical injury

Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had exp…

psychiatryemergency medicinepaliperidone
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk man…

psychiatrypsychologydiagnosticsystemmethamphetamine
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

… Mental health services discharged NLU with incomplete risk assessment despite documented family violence history, poor medication compliance, psychotic symptoms, and substance abuse; (2) NLU's diagnosis remained unclea…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIC2022-07-28

Finding into death of Master S

17y · Male·Unascertained in the setting of volatile substance abuse

Master S, a 17-year-old Yorta Yorta young man, died on 3 July 2017 at the Bert Williams Hostel from a cause unascertained in the setting of volatile substance abuse (chroming Rexona deodorant). He had a history of e…

paediatricspsychiatrycommunicationsystemrexona deodorant
SAhospital2001-11-09

Coroner's Finding: BALL Norman Samual Dean

35y · Male·neck compression from hanging

A 35-year-old man with a history of depression, substance abuse, and acquired brain injury from assault was admitted to a psychiatric ward…

psychiatrygeneral practicecommunicationsystemcarbamazepine
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hos…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
VICcommunity2024-09-20

Finding into death of Frank Mellia

39y · Male·Drowning in the setting of a very high blood alcohol level

…ng the water with a very high blood alcohol level (0.33g/100mL). He was not a confident swimmer and had a history of anxiety, depression, and alcohol misuse. He had ceased psychological treatment due to financial diffic…

alcohol
SAhome2020-02-10

Coroner's Finding: DAILLER Graziella and MUIR Dion Wayne

48y · Female and male·Ms Dailler: blunt head trauma and multiple sharp force injuries including stab w…

…investigators. The case also revealed that a remanded prisoner retained contact with a protected person because the Department for Correctional Services lacked access to intervention order information.

emergency medicineforensic medicinecommunicationsystemalcohol
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

Jose da Silva, a 34-year-old man with a history of schizophrenia and problematic alcohol use, disappeared on 30 April 2017 from Perth, Western Australia.…

psychiatrygeneral practiceolanzapine
NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

…end the safer 'two-out' cell placement despite Tane's recent seizure, emerging mental distress, and known history of self-harm. The cell contained an obvious hanging point. Key clinical lessons include: always obtain an…

emergency medicineneurologydiagnosticcommunicationparacetamol
112131419

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