Coronial

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VIChome2019-10-07

Finding into death of Tre Leigh Lawson

21y · Male·Hanging

…-sentence assessment for a Community Corrections Order in October 2017 failed to recommend mental health treatment conditions, despite evidence of prior required attendance at mental health services and documented self-…

psychiatryemergency medicinecommunicationsystemmethamphetamine
SAhome2024-09-13

Coroner's Finding: McKinley-Glen, Haydn James

22y · Male·neck compression due to hanging

A 22-year-old man with treatment-resistant schizophrenia died by hanging while under guardianship with special powers of detention in sup…

psychiatryemergency medicinepaliperidone
QLDhome2005-11-16

Perry, Jye Conrad (a child)

3y · Male·fatal stab wounds to the heart inflicted by his aunt Natalia Perry during an app…

…s fatally stabbed by his aunt, Natalia Perry, a forensic patient with schizophrenia on limited community treatment (LCT), shortly after being discharged from emergency department. Perry had jumped from a ferry days earl…

psychiatryemergency medicinediagnosticcommunicationrisperidone
TAScommunity2023-05-08

Coroner's Finding: Johns, Ross Alexander

36y · Male·hanging, with contributing factors of alcohol dependence and depression

…n 9 June 2021 following admission for overdose and suicide attempt. The coroner found no deficits in his treatment or care, and that procedures and protocols were correctly followed. His family raised concerns about pre…

psychiatryemergency medicineprescription medications at therapeutic levels
QLD2022-06-03

Kermode, Jesse Aaron

24y · Male·Gunshot wounds to the chest and abdomen

…r being shot by police at Ipswich Railway Station on 16 September 2018. He had a longstanding history of treatment-resistant schizophrenia and substance abuse, with repeated documented psychotic episodes and poor medica…

psychiatryaddiction medicinemethamphetamine
SAhospital2020-11-02

Coroner's Finding: BROWN Graham Douglas

79y · Male·combined cardiac, respiratory and renal failure as terminal events on a backgrou…

…combined cardiac, respiratory and renal failure. He was subject to a Level 2 Mental Health Act Inpatient Treatment Order at the time of death, making this a mandatory inquest. The coroner found that care and treatment p…

psychiatryemergency medicinemorphine
VIChospital2023-11-30

Finding into death of John Rose

58y · Male·Aspiration pneumonia, in the setting of epilepsy and Down's syndrome

… developed aspiration pneumonia during his hospital stay, which did not respond adequately to antibiotic treatment. He deteriorated with increasing drowsiness and oxygen desaturation, and was subsequently transferred to…

emergency medicinegeneral medicineantibiotics
SAhospital2016-10-10

Coroner's Finding: MACMILLAN Kay Meredith

62y · Female·end-stage heart failure due to cardiac amyloidosis

…yloidosis died from cardiogenic shock approximately 90 minutes after being placed on a Level 1 inpatient treatment order. She had wished to discontinue treatment, reflecting her terminal condition and in alignment with …

cardiologypsychiatrydiagnosticcommunicationmirtazapine
NSW2020-06-23

Inquest into the death of Kingsley EAGER

80y · Male·Hodgkin lymphoma and the consequences

…th advanced Hodgkin lymphoma, died of natural causes in Long Bay Hospital. He had declined active cancer treatment on initial diagnosis, preferring alternative approaches. Following disease progression and deterioration…

haematologypalliative careceftriaxone
NT2015-08-14

Inquest into the death of Virginia Brown

46y · Female·Cardiac arrest of unknown origin

…died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alcohol Programmes Unit) in Alice Springs. She had …

emergency medicineaddiction medicinediagnosticcommunicationsodium_valproate
QLD2022-11-15

Childs, Dennis William

64y · Male·Peritonitis, due to or as a consequence of a ruptured gallbladder, due to or as …

…s given morphine and managed conservatively. The following day, he deteriorated critically and underwent emergency surgery but died from multi-organ failure. Clinical concerns were raised about the initial assessment, d…

emergency medicinegeneral surgerydiagnosticdelaymorphine
SAhospital2020-07-02

Coroner's Finding: SWINGLER Yvonne Mary

86y · Female·multi-organ failure due to sepsis

…ultiple comorbidities was admitted with acute delirium and paranoia, subsequently placed on an Inpatient Treatment Order. She developed sepsis secondary to staphylococcal salivary gland infection, likely triggered by he…

psychiatryemergency medicinemorphine
TAShome2020-07-16

Coroner's Finding: Alsop, Olaf Paul

54y · Male·asphyxia due to hanging

…ing palliative care. In his final months, he made escalating requests for pain medication. His GP ceased treatment due to concerns about medication-seeking behaviour and dishonesty about drug use. The patient became dis…

general practicepalliative carecodeine
VICaged care2020-11-06

Finding into death of VA

73y · Female·Combined effects of congestive cardiac failure, coronary artery atherosclerosis …

…ac patients with concurrent acute infections and psychiatric conditions who may refuse investigations or treatment. Early recognition of deterioration and vital sign monitoring in non-compliant patients remain important…

psychiatryintensive caremetaraminol
SAmental health2020-06-17

Coroner's Finding: COULTER Brenton Thomas

60y · Male·Ischaemic heart disease

… died of acute ischaemic heart disease while an inpatient in a mental health facility under an Inpatient Treatment Order. He was admitted for psychiatric management after non-compliance with clozapine. He was found unre…

psychiatrycardiologyclozapine
NT2017-10-13

Inquest into the death of John Roberts

37y · Male·water intoxication and olanzapine toxicity in association with schizophrenia

A 37-year-old Aboriginal male prisoner with a long history of treatment-resistant schizophrenia died at the Darwin Correctional Precinct. He was on high-dose olanzapine (15mg t…

psychiatryemergency medicineolanzapine
SAhospital2017-04-19

Coroner's Finding: O'REILLY Raymond John

91y · Male·pneumonia on a background of chronic congestive cardiac failure and chronic obst…

…ygen therapy despite dangerously low saturations. A Level 1 Mental Health Act order was placed to enable treatment restraint. He received olanzapine for agitation and antibiotics for pneumonia but did not respond to tre…

geriatric medicineemergency medicineolanzapine
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

…aged from community mental health services despite outreach attempts. The patient had capacity to refuse treatment and couldn't be involuntarily detained without acute crisis. Earlier recognition of disengagement, proac…

psychiatrygeneral practicesystemdelaypaliperidone
SAhospital2000-05-31

Coroner's Finding: DELLATORRE Natale

54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…

… and tracheostomy. Communication breakdown occurred between ICU staff and family regarding withdrawal of treatment.

emergency medicinepsychiatrydiagnosticadrenaline
SAhospital2001-12-14

Coroner's Finding: OVERLAND Harold Kelvin

74y · Male·myocardial infarction

…ct at Royal Adelaide Hospital. He had presented with hypokalaemia and sigmoid volvulus, refusing initial treatment. He was detained due to delirium and combativeness, allowing restraint and treatment. His condition dete…

emergency medicinecardiologyproceduralcommunication

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