Coronial

845 results for substance use

TAS2024-10-03

Coroner's Finding: Martin, Thomas David Findings

33y · Male·ketoacidosis, likely alcoholic ketoacidosis

…on facility in Hobart. He had a long history of schizophrenia, involuntary mental health admissions, and substance misuse. In the weeks before death, he exhibited concerning behaviours including drug manufacturing, diso…

psychiatrygeneral practicealcohol
VIChome2010-03-17

Finding into death of Paul Gledhill

37y · Male·smoke inhalation

…munity mental health services on a Community Treatment Order, died from smoke inhalation in an accidental house fire. He had a blood alcohol level of 0.230-0.238% (nearly five times the legal driving limit) and cannabis…

psychiatryforensic medicineflupenthixol
VICcommunity2024-05-02

Finding into death of Rodney Norman Galvin

21y · Male·Unascertained causes

…ive police investigation and multiple proof-of-life checks over decades, his body was never found and the cause and circumstances of death remain unascertained. Several theories emerged including possible homicide by tw…

delaymethamphetamine
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

…cribed high-dose tramadol (700-800mg daily) for chronic pain over 22 months by his GP without documented substance abuse assessment, despite documented history of polysubstance dependence. When Eckersley ceased alcohol …

general practicepain medicinemedicationcommunicationtramadol
VIChome2025-04-01

Finding into death of Jack Elliot Atkinson

26y · Male·Drug toxicity (1,4 butanediol, gamma hydroxybutyrate, methylamphetamine, cocaine…

…caine, novel benzodiazepines (bromazolam, flubromazepam), nordiazepam, and ketamine. He had a history of substance use disorder since age 16, successfully completed rehabilitation in May 2022, but relapsed after an over…

general practiceaddiction medicine1,4-butanediol
TAScommunity2026-01-13

Coroner's Finding: Joshua James Tyrrell

28y · Male·Multiple head, facial and spinal injuries sustained in a single vehicle motorbik…

…essants (benzodiazepines, opioids, antidepressants). Key clinical lessons: (1) Mr Tyrrell had documented substance use disorder with clear drug-seeking behaviour recognised by most treating doctors; (2) prescribing of m…

general practiceemergency medicinemedicationcommunicationdiazepam
NSWhome2017-03-07

Inquest into the death of Louis NAUMOVSKI

59y · Male·Unascertained

Louis Naumovski, a 59-year-old man with a long history of substance use disorder, chronic pain, depression, and multiple suicide attempts, was found deceased at his home af…

addiction medicinepain medicinefentanyl
WAcommunity2019-08-01

Inquest into the Death of Matthew James BALE

38y · Male·Unascertained; death in the waters of the Indian Ocean off Rottnest Island

…ther than suicide. Clinical lessons include recognising the vulnerability of individuals with concurrent substance use disorders, mental health conditions, and acute intoxication, and the importance of risk assessment a…

psychiatryaddiction medicinecitalopram
VICcommunity2025-01-06

Finding into death of F T

19y · Male·Injuries sustained in a motor vehicle collision (driver)

… hallucinogenic impairment causing distorted vision and impaired judgment, excessive speed, and no seatbelt use. No mechanical faults were identified. The coroner noted the behavioural effects of psilocybin—including di…

psilocybin
QLDhome2025-06-25

Non-inquest findings into the death of an eight month old twin whose family was known to Child Safety

0y · Male·Severe acute dehydration and acute malnutrition

…al, insufficient emphasis on interstate child protection history, and inadequate practice frameworks for substance-misusing parents.

paediatricsemergency medicinediagnosticsystemmethamphetamine
VIChome2023-02-27

Finding into death of Jayden Kain Wright

24y · Male·Combined drug toxicity (clonazepam, diazepam, methadone, tramadol, pregabalin)

…wledge. His GP prescribed tramadol, pregabalin, clonazepam, and quetiapine, unaware of concurrent methadone use or his partner's contributions to his medication supply. Clinical lessons include: GPs must actively assess…

general practiceforensic medicinediagnosticsystemclonazepam
VIChome2013-10-11

Finding into death of LP

31y · Male·Multidrug overdose including heroin

LP, a 31-year-old man with depression, severe anxiety, and substance use disorder, died from multidrug overdose including heroin. He had long-standing benzodiazepine (Xanax)…

pathologypsychiatryheroin
VIC2025-05-14

Finding into death of Dean Jenkins

33y · Male·unascertained

Dean Jenkins, a 33-year-old with a history of drug use, disappeared on 24 August 2016 after being observed acting paranoid and erratically while substance-affecte…

methamphetamine
VICcommunity2020-11-27

Finding into death of Nicholas Daniel Ficarra

26y · Male·unascertained; suspected suicide by firearm

…, aged 26, disappeared on 14 January 2012 from his family farm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 2009, including paranoid …

psychiatrygeneral practicesystemdelayheroin
QLDhome2021-02-17

B, an eleven week old infant - Non-inquest findings

0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying

…0am; the baby was discovered head-down beside the bed at 6:30am. Autopsy could not conclusively determine cause of death but indicated probable SIDS or asphyxiation from co-sleeping/overlay. Clinical lessons include: re…

paediatricspathologysystemcommunicationcannabis
VIChome2011-07-18

Finding into death of Susan Michelle Patterson

27y · Female·mixed methadone and alcohol intoxication

Susan Patterson, a 27-year-old Aboriginal woman with a history of alcohol and polysubstance use, died from mixed methadone and alcohol intoxication. She consumed an unknown substance from a brown …

forensic medicinetoxicologysystemdelaymethadone
NSWhome2022-05-27

Inquest into the death of WX

54y · Male·gunshot wound to the head

WX, a 54-year-old with longstanding depression, substance abuse (opioids, benzodiazepines), and a 2008 suicide attempt, died by gunshot wound on 27 April 2015. De…

psychiatrypsychologysystemcommunicationcodeine
SAhome2016-08-04

Coroner's Finding: KALME Dearne Lee

51y · Female·undetermined - either citalopram toxicity or ischaemic heart disease

…ally lethal citalopram level, and autopsy showed significant atherosclerotic coronary artery disease. The cause of death was undetermined, as either citalopram toxicity or ischaemic heart disease could have been fatal. …

psychiatrycardiologycitalopram
VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

…g toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identified during initial assessment. During day leave on 23 April 2023, she obtained drugs …

psychiatrygeneral practicesystemcommunicationmorphine
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

…H once. Despite MJU calling emergency services at 12:40pm reporting CTH's hallucinations, paranoia and drug use, paramedics and police assessed him as not meeting Mental Health Act thresholds for involuntary admission. …

psychiatryemergency medicinediagnosticcommunicationmethamphetamine

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