Coronial

368 results for substance use disorder history

WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 Nove…

psychiatryintensive carecommunicationsystempaliperidone
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synth…

emergency medicineintensive caresystemmethadone
VIC2022-03-03

Finding into death of Andrew William Staker

55y · Male·Pulmonary thromboembolism secondary to deep thrombosis, with WHO Class 3 obesity…

…from left lower leg thrombus. Although Mr Staker had multiple cardiovascular risk factors and frequently refused medical appointments, the coroner found his emergency management appropriate and custodial care met standa…

forensic medicineemergency medicinefluoxetine
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 parol…

psychiatryemergency medicinesystemdelaycannabis
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
QLD2018-06-20

Holstein, Zachary James David

23y · Male·Hypoxic-ischaemic encephalopathy due to hanging

… hanging in Woodford Correctional Centre on 8 February 2016 (declared extinct 12 February 2016). He had a history of substance abuse, self-harm, and mental health difficulties. The key clinical lesson concerns informati…

psychiatrycorrectional healthdelaysystemmirtazapine
QLDhome2009-10-16

Anderson, Andrew Scott

14y · Male·gunshot wound to the head

… placed in Department of Child Safety care following his father's physical assault. He had a longstanding history of behavioral difficulties, ADHD, depression, and substance use (chroming, marijuana, amphetamines). The …

psychiatrypaediatricsdiagnosticcommunicationmarijuana
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

…n's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adeq…

psychiatryemergency medicinecommunicationsystemmethadone
VIChome2016-06-24

Finding into death of SJD

54y · Male·mixed pentobarbitone and alcohol toxicity

…lf with pentobarbitone (a veterinary euthanasia drug) while under the influence of alcohol. He had a long history of alcohol abuse and gambling, with escalating problems following drink-driving convictions and loss of e…

occupational and environmental healthpsychiatrypentobarbitone
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
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

…a 24-year-old Aboriginal man, died by hanging on 19 May 2019 following a relationship breakdown. He had a history of depression, self-harm, and previous suicide attempts. In the weeks before his death, he experienced mu…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
NSWaged care2020-07-29

Inquest into the death of John Pocklington

31y · Male·Acute Myocardial Infarction

John Pocklington, aged 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,…

cardiologypsychiatrydiagnosticcommunicationmethamphetamine
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 …

psychiatrygeneral practicecommunicationsystempropranolol
WAcommunity

Inquest into the Death of Kim Martin FRANKER

36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…

A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescri…

psychiatrygeneral practicecommunicationsystembenzhexol
ACTcommunity2015-06-30

INQUEST INTO THE DEATH OF MARK RODNEY JOLLIFFE

37y · Male·Hanging, self-inflicted with intention of taking own life

A 37-year-old man with schizophrenia and a history of medication non-compliance died by suicide while subject to a Psychiatric Treatment Order. He was last …

psychiatrycommunicationzuclopenthixol
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He…

psychiatrygeneral practicediagnosticsystemduloxetine
QLDhome2017-07-26

Richards, Karen Louise

41y · Female·mixed drug and alcohol toxicity

…cal lessons: rapid recognition of altered consciousness and immediate emergency response are critical; drug users and their contacts require education on overdose recognition and first aid; delay in treatment initiation…

psychiatryemergency medicinedelaysystemheroin
QLDhome2013-05-03

Thompson, Leanne Melissa

15y · Female·Hypoxic brain injury due to hanging

…nd vulnerable young woman under a Child Protection Order, living with 28-year-old Alexander O'Sachy, a drug user and violent offender. She had a history of self-harm, drug abuse, and high-risk behaviours. On 7 September…

paediatricspsychiatrysystemdelayheroin
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

…Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and borderline personality disorder, substance use, and intellectual disability. Criti…

psychiatryemergency medicinediagnosticcommunication
VIChospital2021-09-27

Finding into death of Abigail Louise Cooke-Mitchell

42y · Female·Traumatic right subdural haematoma

A 42-year-old woman died from a traumatic right subdural haematoma sustained on 22 January 2015. She was found unresponsive at home with severe head and facial injuries after falls. Critical delays in medical assessment …

emergency medicineneurosurgerycommunicationdelaymorphine
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