Coronial

415 results for drug abuse

VIChome2023-02-22

Finding into death of Anna Lawrence

64y · Female·Combined toxicity to alcohol and baclofen

Anna Lawrence, 64, died from combined toxicity of alcohol and baclofen on 30 April 2020. She had a 40+ year history of alcohol dependency, borderline personality disorder, depression, and multiple suicide attempts. Baclo…

psychiatrypsychologysystembaclofen
NSWhome2018-07-27

Inquest into the death of Alissa Campbell

26y · Female·Multiple drug toxicity

Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with …

general practiceaddiction medicinediagnosticmedicationcodeine
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
NT2025

Inquest into the death of Kumanjayi Walker

19y · Male·gunshot wounds to chest and abdomen

…Aboriginal communities. Key clinical/public health lessons include: inadequate mental health and substance abuse services contributed to vulnerabilities; failures in early intervention for young people with developmenta…

public healthpsychiatrycommunicationsystem
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

… Prison, died by ligature compression of the neck (hanging) on 4 April 2003. He had a history of self-harm, drug-induced psychosis, violent offences against his de facto partner, and was deeply concerned about lack of vi…

psychiatrypsychologydiagnosticcommunication
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

…ttempt reported by police. Dr G. prescribed unrestricted diazepam (50 tablets) despite Mr Ryan's substance abuse history, and conducted only a 10-15 minute discharge assessment without reviewing the file. When Mr Ryan r…

psychiatrygeneral practicecommunicationdocumentationsertraline
NSWhome2020-06-05

Inquest into the death of BG

30y · Male·neck compression from ligature strangulation and possible suspension (hanging)

…e on recognising clusters of psychosocial risk factors—financial crisis, relationship breakdown, substance abuse history, and expressed hopelessness—as warning signs for imminent suicide risk, particularly in culturally…

psychiatryemergency medicinedelay
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide atte…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhome2026-01-23

Inquest into the Death of Sean Theo WINMAR (Mr STW)

46y · Male·Complications of ligature compression of the neck (hanging)

… primary risk factor; and (3) inadequate cultural considerations in his management. Mr Winmar relapsed into drug use and feared returning to prison before his court hearing. The coroner found that earlier psychological s…

general practiceaddiction medicinesystemdelaymethamphetamine
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

…ear-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescriptions from…

general practicepsychiatrymedicationdiagnosticcodeine
QLDhome2021-05-13

Baby J - Non-inquest findings

0y · Unknown·Category II Sudden Infant Death Syndrome (co-sleeping)

…f Child Safety failed to conduct proper investigations despite multiple notifications of domestic violence, drug use, and family instability. An initial investigation for the unborn child was incorrectly closed without l…

paediatricsemergency medicinesystemcommunicationmethamphetamine
VIChospital2012-10-25

Finding into death of Fikri Memedovski

30y · Male·Heroin overdose

Fikri Memedovski, aged 30, died from heroin overdose with resulting cardiopulmonary arrest and anoxic brain damage on 23 November 2009 at Dandenong Hospital. The clinical lesson concerns reporting obligations: Dr L., the…

intensive carepsychiatrycommunicationsystemheroin
WAhome

Inquest into the Death of Anthony William KUSTER

44y · Male·Ligature compression of the neck and methylamphetamine effect

Anthony William Kuster, a 44-year-old man, died from ligature compression of the neck combined with methylamphetamine toxicity. He applied a tourniquet around his neck while heavily intoxicated with methylamphetamine aft…

toxicologyforensic medicinedelaymethamphetamine
VIChospital2018-11-09

Finding into death of MDJ

34y · Male·Hypoxic/ischaemic encephalopathy; Heroin toxicity

A 34-year-old man with a history of heroin abuse died from hypoxic-ischaemic encephalopathy following heroin toxicity after injecting in a public park. He …

intensive careemergency medicineheroin
SA2017-02-17

Coroner's Finding: MCPHERSON Lewis Mike

18y · Male·Gunshot wound to chest

…2. The coroner found the death was preventable. 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 J…

communicationsystemcannabis
NSWmental health2014-06-18

Inquest into the death of Mark Richard GLEESON

39y · Male·respiratory failure as a result of the interaction of prescribed medication and …

Mark Richard Gleeson, 39, died from respiratory failure caused by the combined effect of prescribed antipsychotic/anxiolytic medications (olanzapine, quetiapine, clonazepam) and alcohol consumed within hours of discharge…

psychiatryolanzapine
VIChospital2021-12-13

Finding into death of Baby A

1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown c…

…c and neurological risks; and apparent lack of pain manifestation despite serious injuries may have masked abuse. Earlier identification of the partner's family violence history and drug use, combined with improved info…

paediatricsemergency medicinesystemcommunicationmethamphetamine
VIChome

Finding into death of Aaron James McDonald

22y · Male·Asphyxia from recreational use of nitrous oxide

Aaron McDonald, 22, died from asphyxia while using nitrous oxide recreationally alone at home, breathing the gas through apparatus connected to a canister. He had sourced knowledge and equipment from the internet and ret…

forensic medicinenitrous oxide
SAcommunity2011-05-12

Coroner's Finding: KILTIE Andrew

52y · Male·clozapine toxicity

Andrew Kiltie, 52-year-old Aboriginal man, died from clozapine toxicity on 26 December 2007. He had been on clozapine 400mg daily for 5 years with significant clinical benefit for aggressive behaviour and psychosis, enab…

psychiatrycardiologyclozapine
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

…us concerns about restraint training, procedural safety, and inadequate monitoring of access to alcohol and drugs that precipitated his acute deterioration.

psychiatryintensive careproceduralsystemhaloperidol
117181921

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