Coronial

568 results for overdose

TAScommunity2021-11-18

Coroner's Finding: Wheldon, Jamie Damien

45y · Male·methylenedioxymethylamphetamine (MDMA or 'ecstasy') toxicity

…d, obtaining and ingesting MDMA. His reduced tolerance following abstinence may have contributed to fatal overdose. The coroner found the death accidental. Clinical lessons include: recognizing relapse risk in substance-…

addiction medicinepsychiatryMDMA
VICmental health2017-04-07

Finding into death of Natasha Calleja

32y · Female·combined drug toxicity, mainly heroin

…ivate spaces with a visitor of known drug involvement, and failure to educate patients and visitors about overdose risks after abstinence. Heroin's interaction with her prescribed psychotropic medications (diazepam, amit…

psychiatryemergency medicinecommunicationsystemheroin
VIC2010-05-28

Finding into death of Katherine Fiona Walton

47y · Female·insulin overdose

Katherine Walton, a 47-year-old registered nurse, died from insulin overdose in April 2007. She had a complex medical history including hepatitis C, depression, chronic back pain, ep…

emergency medicinepsychiatrycommunicationsysteminsulin
VICcommunity2013-12-20

Finding into death of Jade Lesley Dorogi

25y · Male·Cerebral hypoxia and multisystem organ failure from heroin (morphine) toxicity

… heroin use. Daniel, aware of heroin's lethal risks in naive users and having lost two brothers to heroin overdose, acknowledged his failure to respond appropriately and expressed remorse. The clinical lesson involves re…

forensic medicineemergency medicinedelayheroin
SAhome2025-11-27

Coroner's Finding: Christian, Jake Nicholas

27y · Male·heroin toxicity

…vided during home detention and made no recommendations. This case highlights the unpredictable nature of overdose risk even in individuals appearing stable and compliant with supervision.

psychiatrygeneral practiceheroin
SAhome2012-09-25

Coroner's Finding: AMOS Mark Geoffrey

37y · Male·Morphine toxicity from accidental overdose of crushed Kapanol (slow-release morp…

A 37-year-old male subject to home detention bail died from morphine toxicity due to accidental overdose of crushed Kapanol (slow-release morphine capsules). He had a long history of polysubstance abuse, enceph…

toxicologyaddiction medicinesystemdelaymorphine
VICmental health2017-11-14

Finding into death of Sandra Michelle Liddy

44y · Female·Heroin toxicity

…d her care was clinically sound. On 16 December, during approved leave, she used heroin intravenously and overdosed. Critical learning: her lowered opioid tolerance from three years of abstinence meant she did not adjust…

psychiatryemergency medicineheroin
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

…hronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was prescribed multiple opioids (fentanyl, tramadol, oxycodone), benzodiazepines, pregabalin and sert…

general practiceneurologymedicationcommunicationfentanyl
VICcommunity2017-05-08

Finding into death of David Leslie Chapman

39y · Male·Hypoxic ischaemic brain injury

David Leslie Chapman, age 39, collapsed from a suspected heroin overdose in Richmond on 9 June 2016 and died from hypoxic ischaemic brain injury on 17 June 2016. He had a lengthy…

emergency medicineintensive careheroin
NSW2020-09-04

Inquest into the death of Ivan MIKIC

34y · Male·Methadone toxicity, with coronary artery atherosclerosis as a significant contri…

…am. Clinical lessons include the need for better training of correctional officers to recognise methadone overdose signs and the challenge of balancing prisoner safety checks with operational logistics. The coroner did n…

correctional healthaddiction medicinesystemmethadone
WA2024-07-10

Inquest into the Death of Jason Anthony THOMPSON

54y · Male·metastatic lung cancer with terminal palliative care

…asuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for approximately 10 hours. While not definitively an opioid overdose

emergency medicineoncologydelaynaloxone
QLDhome2017-12-14

Robertson, Charlie Mark John

19y · Male·Toxic effects of multiple drugs, primarily gammahydroxybutyric acid (GHB), causi…

… and unresponsive to multiple arousal attempts for 90 minutes. Officers failed to recognise signs of drug overdose and did not call an ambulance, despite paramedics already being on-site treating another person. The coro…

forensic medicinetoxicologydiagnosticcommunicationgammahydroxybutyric acid
SAhospital2020-10-12

Coroner's Finding: USHER Peter Michael

56y · Male·hypoxic ischaemic encephalopathy following insulin and benzodiazepine overdose

A 56-year-old man with depression, known to close friends but not formally disclosed to healthcare providers, deliberately ingested temazepam tablets accumulated over time and insulin stolen from his mother on 10-11 Nove…

anaesthesiapsychiatrytemazepam
NSWhospital2016-10-26

Inquest into the death of Audrey MacGREGOR

88y · Female·combined effects of an overdose of hydromorphone and complications of pneumonia …

… respiratory distress on 24 October 2013. Two nurses unfamiliar with hydromorphone administered a 10-fold overdose (5 mg instead of 0.5 mg), mistaking the dose unit from milligrams to millilitres and confusing it with mo…

cardiologyrespiratory medicinemedicationcommunicationhydromorphone
VIChome2020-08-24

Finding into death of Wayne Laurence Marshall

54y · Male·Methadone use in a man with asthma and sarcoidosis of the lungs

… methadone diversion represents a substantial public health problem, with one-third of methadone-involved overdose deaths in 2018 involving diverted drug. Key clinical lessons include the high overdose risk of methadone …

emergency medicineintensive caremethadone
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

…diazepam, zopiclone, promethazine). She was admitted to hospital on 4 September 2022 following medication overdose and self-harm, placed on an Assessment Order, then discharged on 6 September after psychiatric assessment…

psychiatrygeneral practicecommunicationsystemtapentadol
NThome2007-11-13

Inquest into the death of Richard Kiel

37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)

…2001 onwards despite knowing Kiel was a serious drug abuser with documented 'red flag' episodes including overdoses in 2003 and July 2005. Key failures included: no documented treatment plan, inadequate medical records, …

general practiceaddiction medicinediagnosticmedicationmethadone
TAShospital2020-05-18

Coroner's Finding: Griffin, James Geoffrey

69y · Male·mixed drug toxicity; oxycodone overdose with doxylamine, temazepam, and naloxone

James Geoffrey Griffin, a 69-year-old man facing multiple charges for historic child sexual abuse, died from mixed drug toxicity involving oxycodone, doxylamine, temazepam, and naloxone. He was admitted to Launceston Gen…

emergency medicineintensive careoxycodone
WA2020-09-04

Inquest into the Suspected Death of Marek PETERA

41y · Male·suicide by unknown method, either through deliberate self-harm or by placing him…

…o 'perish without a trace'. His ex-wife later reported he had experienced lifelong depression, a previous overdose in 1987, and felt his anti-depressant medication was no longer effective. The coroner concluded he died b…

psychiatrygeneral practicediazepam
VICmental health2020-03-13

Finding into death of PATIENT A

35y · Female·mixed drug toxicity (fentanyl, morphine, clozapine and aripiprazole)

…rvision was reduced. She obtained drugs, self-injected or was assisted in injecting, and suffered a fatal overdose. Naloxone was administered by a friend but was unsuccessful. The coroner found no clinical issues with me…

psychiatryfentanyl

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