Coronial

318 results for substance use (cannabis)

QLD2011-10-20

Hornby, Grace Ann; Hornby, Jessica Lee; Mansell, Denise Ann; Thomson, Anthony Paul

Unknown·Multiple injuries from motor vehicle accident; Anthony Paul Thomson died from ru…

…ighlights gaps in medical-police communication regarding driver fitness and over-medication risks in polysubstance-using patients with psychiatric conditions.

general practicepsychiatrysystemcommunicationdextroamphetamine
VIChome2025-04-17

Finding into death of Thomas Vale

Unknown·Toxicity to protonitazene

…le composition of street drugs, the extreme potency of emerging synthetic opioids, the danger of group drug use without safeguards, and the absence of accessible drug checking services at the time. Key clinical lessons …

toxicologyforensic medicineprotonitazene
NSWaged care2020-07-29

Inquest into the death of John Pocklington

31y · Male·Acute Myocardial Infarction

…d 31, died of acute myocardial infarction while in remand custody. He had a long history of methamphetamine use and untreated cardiac damage. On 28 April 2015, he reported chest pain to a nurse, who recorded vital signs…

cardiologypsychiatrydiagnosticcommunicationmethamphetamine
NSWmental health2023-12-15

Inquest into the death of CC

33y · Male·Hanging

CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over …

psychiatryaddiction medicinecommunicationsystemmethamphetamine
VICcommunity2015-09-24

Finding into death of GC

42y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 42-year-old male with a long history of schizophrenia and dissocial personality disorder was released from prison in August 2011 without parole conditions. Despite police and forensic mental health concerns about his r…

psychiatryemergency medicinesystemdelaycannabis
TAScommunity2019-09-09

Coroner's Finding: Wilson, Jacob Leigh

27y · Male·chest and abdominal injuries from single motorcycle crash

…icology revealed multiple prescription drugs (diazepam, quetiapine, fluvoxamine, pregabalin) and illicit substances including opium alkaloids, indicating poppy tea consumption. These central nervous system depressants i…

general practicepsychiatrycommunicationdiazepam
VIChome2015-04-16

Finding into death of Nicholas William Moorby

35y · Male·serotonin syndrome

…spite this exceeding his normal practice. The coroner also noted Dr W. was unaware of Moorby's illicit drug use. Witnesses described Moorby's deteriorating mental state in the days before death—agitation, confusion, mum…

general practicepsychiatrymedicationdiagnosticduloxetine
ACThospital2023-03-08

Inquest into the death of Brontë Haskins

23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…

…cases with minimal resources), delayed CADAS assessment (scheduled one week post-release despite known drug use and suicide risk), failure to arrange mental health bail conditions despite documented suicidality in custo…

psychiatryemergency medicinesystemdelayheroin
QLDcommunity2017-08-17

JJKD - Non-inquest findings

34y · Male·drowning

… opportunities despite multiple warning signs (McDonald's incident, medication non-compliance, illicit drug use, family concerns), and failure to implement structured case reviews. The coroner found poor judgment precip…

psychiatrycommunicationsystemclozapine
VIChome2023-01-19

Finding into death of Danny Lee O'Brien

37y · Male·Stab wound to the chest

…ed in the chest by his intimate partner Kerry Jones on 9 December 2016 during an argument at his boarding house. He had previously assaulted Ms Jones, leading to a Family Violence Intervention Order (FVIO) in May 2015. …

systemcommunicationmethamphetamine
NSWcommunity2023-11-17

Inquest into the death of SB

51y · Male·Stab wounds to the chest

A 51-year-old man with documented mental health issues including psychosis, paranoia, and delusions died from self-inflicted stab wounds during a police siege at his mother's home. He had breached a domestic violence ord…

psychiatryemergency medicinecommunicationsystemolanzapine
VIC2024-10-16

Finding into death of Jessica Anne Thomas

33y · Unknown·neck compression secondary to hanging

Jessica Anne Thomas, a 33-year-old gender-diverse person with complex psychiatric diagnoses including schizoaffective disorder, borderline personality disorder, and PTSD, died by hanging while remanded in custody at Dame…

psychiatryemergency medicinesystemaripiprazole
TAScommunity2016-11-28

Coroner's Finding: Deaths from a Public Place

Suicide by intentional fall or jump from Tasman Bridge

…s-70s) had diverse personal circumstances but shared mental health vulnerabilities: depression, anxiety, substance use (alcohol and/or drugs), and acute stressors (relationship breakdown, grief, work stress, financial c…

psychiatrypublic healthalcohol
TAShome2015-05-27

Coroner's Finding: Pearce, Jasmine Rose

0y · Female·suffocation under bedding

Jasmine Rose Pearce, aged 11 months, died from suffocation under bedding in her family home on 27 January 2013. Her parents engaged in sexual activity on the bed where Jasmine was sleeping while under the influence of ca…

paediatricsemergency medicinesystemdelaycannabis
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

…heir duty to guard Scott and exercise basic security vigilance, though the escape itself did not directly cause his death.

correctional healthemergency medicineproceduralcommunicationmethamphetamine
VIChospital2021-02-24

Finding into death of Shae Harry Paszkiewicz

40y · Male·Mixed drug toxicity

Shae Paszkiewicz, a 40-year-old man with a long history of drug dependence and incarceration, died from mixed drug toxicity five days after being found unconscious following opioid injection. He had been released from pr…

emergency medicinetoxicologysystemcommunicationheroin
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
VIChome2022-08-08

Finding into death of Kim Michelle Cooper

47y · Female·Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)

A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death…

general practiceaddiction medicinemedicationsystempregabalin
VIChome2024-05-13

Finding into death of Victor Dale Fenech

56y · Male·complications of metastatic colorectal carcinoma

…erted to higher priority emergencies. The coroner found no evidence the death was preventable, as Victor refused hospital transport when contact was made, and his prognosis was poor given advanced undiagnosed cancer. Ho…

emergency medicineparamedicinecommunicationsystemcocaine
NSWmental health2019-02-12

Inquest into the death of Kevin O’Halloran

55y · Male·positional asphyxia, with sedation as an underlying risk factor

…ophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg midazolam and 35mg haloperidol) over 20 hours at…

emergency medicinepsychiatrycommunicationproceduralmidazolam

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