Coronial

568 results for overdose

VIChome2025-08-13

Finding into death of Lillian Rose Thomas

21y · Female·Compression of the neck secondary to hanging

…f her death, she contacted Lifeline crisis support and her former teacher Ms Heale, disclosing medication overdose. Ms Heale called 000 at 5:31 am. The call was triaged as Priority 3 (non-urgent) and referred to ambulanc…

psychiatrygeneral practicesystemdelayprazosin
NSWcommunity2023-08-08

Inquest into the death of Simon Miles

42y · Male·heroin and methylamphetamine toxicity

…year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing well through reha…

addiction medicinepsychiatrysystemcommunicationheroin
SAhome2007-11-09

Coroner's Finding: RANDALL Treenor Heather

50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)

Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in …

general practicepsychiatrycommunicationdelayquetiapine
VIChospital2021-05-01

Finding into death of Sharni Dee Connolly

37y · Female·Multiple drug toxicity

… and clonazepam were prescribed in excess of therapeutic need, with concurrent CNS depressants increasing overdose risk. No systemic prevention opportunities were identified, though the SafeScript real-time prescription …

general practiceemergency medicinemedicationcommunicationtapentadol
NSWhome2026-06-02

Inquest into the death of Clem McCullough

Unknown·Mixed drug toxicity

Clem McCullough died between 8-10 June 2019 from mixed drug toxicity. The inquest, held in May 2026, resulted in an open finding as the available evidence did not permit the coroner to determine the place or manner of de…

NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

…d Valium and alcohol after losing money gambling, expressed suicidal intent to his brother, and disclosed overdose with intent. When paramedics assessed him, his presentation appeared calm and coherent. Critical communic…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

…esistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, antidepressants, and analgesics. The coroner identifi…

general practicepsychiatrymedicationcommunicationflunitrazepam
VIChospital2025-08-13

Finding into death of Jordan Thomas Alexander McDonald

0y · Male·complications of extreme prematurity in the setting of precipitant premature bre…

Jordan was born at 25 weeks 4 days gestation in an emergency department following precipitant breech labour with a circumvallate placenta. He received appropriate initial resuscitation but was administered 10 times the p…

neonatologyobstetricsmedicationdiagnosticmorphine
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

…ended inpatient admission; (2) Dr G.'s unreasonable acceptance of Mr Kirkwood's claim that a polypharmacy overdose on 27 April was accidental, despite clear documentation of self-harm history; (3) inadequate response to …

psychiatryemergency medicinediagnosticcommunicationfluoxetine
VICcommunity2019-07-30

Finding into death of Caterina Fratto

45y · Female·Hanging

… health team despite expressing active suicidal thoughts in the days before her death, including a recent overdose attempt. The clinical management was considered appropriate given her capacity to refuse admission and th…

psychiatrygeneral practicecommunicationdocumentationquetiapine
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…

psychiatrygeneral practicesystemmethamphetamine
VICcommunity2021-10-20

Finding into death of Joshua Brown

57y · Male·Clozapine toxicity on a background of right lower lobe of lung lesion (unspecifi…

Joshua Brown, a 57-year-old man with treatment-resistant schizophrenia managed in the community, died from clozapine toxicity. He had accumulated over 50 tablets of clozapine at home despite being prescribed 550mg daily …

psychiatrytoxicologycommunicationsystemclozapine
SAhospital2006-06-16

Coroner's Finding: SMITH Ian Myles

2y · Male·morphine toxicity

A 2-year-old boy died from morphine toxicity approximately 35 hours after suspected ingestion of up to 7 Kapanol (slow-release morphine) capsules accessed from his father's medication left unguarded in the home. Hospital…

emergency medicinepaediatricssystemdelaymorphine
VIChome2025-01-31

Finding into death of FCP

45y · Female·Drowning whilst inebriated (ethanol)

…busive dynamics. Following a deterioration in mental health during a visit to NSW (including a medication overdose on 1 April), she was discharged from Grafton Hospital on 7 April with a 7-day medication supply. The coro…

psychiatryemergency medicinesystemcommunicationalcohol
WAaged care2013-09-11

Inquest into the Death of Taylor, Evelyn

87y · Female·heart failure and probable pneumonia in an elderly lady complicated by morphine …

An 87-year-old woman with dementia, heart disease, and hypertension presented with chest pain and hypoxia. A locum doctor (Dr B.) administered 20mg morphine intramuscularly without reviewing the patient's notes, medical …

emergency medicinegeneral practicemedicationdiagnosticmorphine
WAhome2013-09-05

Inquest into the Death of Doherty, Craig James

39y · Male·propofol toxicity

…ile Doherty had a prior suicide attempt in 2008, evidence supported an accidental rather than intentional overdose. Key clinical lessons include: propofol requires stricter controls despite operational complexity; health…

anaesthesiapharmacysystemdelaypropofol
VICcommunity2025-08-25

Finding into death of Tracey Ellen Knowles

42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…

Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…

forensic medicinetoxicologysystemcommunicationheroin
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

…ic inpatient care. He was admitted to Lyell McEwin Health Service on 16 February 1999 following a serious overdose, diagnosed with major depressive disorder by an experienced registrar, and placed on Ward 1G. However, Dr…

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
SAcommunity2002-05-23

Coroner's Finding: DANN Kathleen Felicity

38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…

…f high-dose benzodiazepines and tricyclic antidepressants with ongoing heroin use significantly increased overdose risk through central nervous system and respiratory depression. Key clinical lessons: GPs managing poly-s…

general practiceaddiction medicinemedicationdiagnosticheroin
WAhome2019-05-10

Inquest into the Death of Matthew Neil Hardy TONKIN

24y · Male·bronchopneumonia complicating oxycodone toxicity

…on shopping across multiple doctors and pharmacies, obtaining oxycodone and benzodiazepines despite prior overdoses. A GP in Claremont prescribed controlled-release oxycodone (20mg and 80mg tablets) on 1 July 2014 withou…

general practicepain medicinediagnosticcommunicationoxycodone
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