Coronial
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…

emergency medicinepsychiatrymedicationsystemclonazepam
WA2018-05-02

Inquest into the Deaths of Chantelle Jane McDOUGALL, Leela McDOUGALL, Antonio Konstantin POPIC and Gary FELTON

Female·not established beyond reasonable doubt

…ranscendence, and access to sedative medications), or they orchestrated disappearances and are living in seclusion (supported by their deceptive practices, preparation activities, Simon's history of assuming false ident…

delaysystemdiazepam
VIChospital2023-10-05

Finding into death of Ruby-Lee Gold

28y · Female·Multiple injuries sustained in a fall from height

Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…

psychiatryemergency medicinesystemdelaydiazepam
VICmental health2015-07-03

Finding into death of Anthony Travaglini

40y · Male·combined drug toxicity in a man with asthma (undiagnosed) and sleep apnoea

Anthony Travaglini, a 40-year-old with schizoaffective disorder, severe sleep apnoea, and undiagnosed asthma, died from combined drug toxicity on a psychiatric high-dependency unit. Critically, his earlier clinical recor…

psychiatryrespiratory medicinesystemcommunicationzuclopenthixol
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
NSWhospital2023-07-21

Inquest into the death of Ziad Hamawy

51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …

…oncerning weekend behaviour (aggression, delusions, paranoid thinking, secreting razor blades, requiring seclusion). Critical clinical lessons include: the importance of considering the full context of a patient's prese…

psychiatryemergency medicinediagnosticcommunicationheroin
QLDmental health2007-06-01

Huntington, Sparka Isarva aka Huntington, James Philip

31y · Male·Undetermined; most likely coronary atherosclerosis leading to arrhythmia, but as…

Sparka Huntington, a 31-year-old forensic mental health patient with a history of schizophrenia, violence, and drug use, died during physical restraint by hospital security officers and nursing staff on 14 December 2003.…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Clinical…

psychiatryintensive caresystemcommunicationrisperidone
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

Nigel Douglas Roberts, a 55-year-old man with chronic schizophrenia, COPD, and cardiomyopathy, died from cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and olanzapine) in the presence of adv…

psychiatryemergency medicinemedicationdiagnosticclozapine
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

…rom massive PE. Key clinical lessons: (1) The referring unit lacked adequate psychiatric infrastructure, seclusion facilities, and ECT capability for managing acutely aggressive patients; (2) Family communication was mi…

psychiatryintensive caresystemdelayaripiprazole depot
NT2025-08-12

Inquest into the death of Didbala Anzac

17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…

Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…

psychiatrypsychologycommunicationsystemcannabis
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…

psychiatryemergency medicineproceduralcommunicationmidazolam
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
QLD2015-08-14

O'Connor, Scott Matthew

31y · Male·Hanging

Scott Matthew O'Connor, a 31-year-old male, died by suicide in the Maximum Security Unit of Arthur Gorrie Correctional Centre on 22 January 2013. He had been assessed as high-risk for self-harm and placed on 30-minute ob…

psychiatrypsychologydiagnosticproceduraltramadol

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