Coronial

464 results for substance use history

TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

…multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression dating from age 14, treated with antipsychotic medication with variable compl…

psychiatryemergency medicinedelaymethamphetamine
NSWcommunity2026-01-20

Inquest into the disappearance and suspected death of AL

35y · Male·The available evidence does not allow for any finding to be made as to the cause…

A 35-year-old male with extensive mental health history died by intentional self-inflicted means on 13 September 2022 at Vaucluse, NSW. He had multiple psychiatr…

psychiatrypsychology
VIChome2023-07-28

Finding into death of Jackson Desmond David Stawicki

24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm

…aemorrhagic shock following a sharp force injury to his left arm while intoxicated with multiple illicit substances. He presented to the ED three times within 24 hours (4-5 September 2020) following police apprehension …

emergency medicinepsychiatrycommunicationsystemflualprazolam
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
SAhome2002-05-23

Coroner's Finding: DAVIES Nicole Memory Faye

17y · Female·mixed drug toxicity

…n, diazepam, fluoxetine). Critical failures included: inadequate investigation of her complex psychiatric history and previous Melbourne methadone treatment; escalating methadone by 35mg over 5 days (contrary to guideli…

general practiceaddiction medicinediagnosticmedicationmethadone
VICcommunity2019-02-25

Finding into death of DH

40y · Female·Clozapine toxicity in a woman with cardiomegaly

…odiazepines and alcohol. Clinical lessons include: PRCs must actively manage medication sharing and alcohol use despite promoting resident independence; family relationships are protective factors requiring active suppo…

psychiatrygeneral practicesystemcommunicationclozapine
VIC2008-02-20

Finding into death of Georgie Lopiccolo

47y · Female·Neck compression (ligature strangulation)

…e custody after arrest on outstanding warrants. She had documented mental health issues (depression) and substance abuse history, with a suicide warning flagged on police systems. Critical failures occurred: pantyhose r…

communicationsystem
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
SA2018-06-28

Coroner's Finding: CLAVELL Rodney Ian

46y · Male·Shotgun wound to the head (self-inflicted)

…yn's premises in Adelaide on 5 June 2014. Clavell was a high-risk wanted offender with extensive criminal history, substance abuse (methamphetamine, cocaine, steroids), and known violent behaviour. Police implemented a …

communicationmethamphetamine
QLDhome2019-07-15

Male child aged 20 months - Non-inquest findings

20y · Male·Lung infection on a background of oxycodone intoxication

…regarding drug-seeking behaviour, and proper assessment of drug dependence before prescribing Schedule 8 substances.

general practiceforensic medicinediagnosticmedicationoxycodone
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
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
VIChome2012-05-18

Finding into death of David Andrew Trengrove

38y · Male·Toxic effects of morphine in a setting of benzodiazepine dependency

…nes and opioids from five different doctors through 'prescription shopping'—a practice he could conceal because no real-time system existed to track prescriptions across providers. One doctor prescribed excessive quanti…

general practicepsychiatrymedicationcommunicationmorphine
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

Amanda Kennedy, a 26-year-old woman with a history of trauma, substance abuse, depression, and multiple suicide attempts, died by hanging in the Northern Ps…

psychiatryemergency medicinecommunicationsystemquetiapine
TAShome2018-11-16

Coroner's Finding: Taylor, Michael John

50y · Male·methadone and alprazolam intoxication

…hing and injecting his prescribed methadone tablets, a practice inherently dangerous due to pill binding substances causing lung and vascular damage. He was found unresponsive at home approximately 1.5 hours after becom…

general practicepain medicinecommunicationsystemmethadone
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 House) on 3 January 2012. He was adm…

psychiatryforensic medicinecommunicationdiazepam
TAShome2020-05-12

Coroner's Finding: Riley, Shane Patrick

53y · Male·Incineration from accidental house fire

Shane Patrick Riley, aged 53, died in an accidental house fire at his residential unit in Latrobe, Tasmania on 11 June 2019. The fire originated from combustible mat…

NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

…ntre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 6…

psychiatrycardiologycommunicationdiagnosticamisulpride
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
VIChome2018-11-07

Finding into death of Abuk Derder Akek

19y · Female·Stab wounds to the abdomen

…ault at her home in Melton, Victoria on 13 March 2016. The finding identifies that Banek had a documented history of escalating domestic violence, controlling behaviour, and threats to kill. Key clinical and systemic le…

psychiatrygeneral practicediagnosticsystem
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