Coronial

37 results for substance-seeking behaviour

NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

…ing; ensuring robust communication systems for clinically significant observations (patient drug-seeking behaviour); strict medication administration oversight; and maintaining advanced life support training for all sta…

psychiatryemergency medicinecommunicationsystemdiazepam
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

22y · Male·Mixed drug toxicity (tapentadol, clonazepam, citalopram, amphetamine, olanzapine…

Laurence O'Brien, a 22-year-old with acquired brain injury from a childhood motor vehicle accident, died from mixed drug toxicity involving eight substances including prescribed opioids, benzodiazepines, and unprescribed…

general practicepsychiatrymedicationsystemtapentadol
TAShome2026-01-07

Coroner's Finding: de-identified UN

43y · Male·hypoxic brain injury caused by cardiac arrest due to unintentional drug poisonin…

…cribed large quantities of pregabalin, temazepam, and tramadol by his GP despite documented drug-seeking behaviour and illicit substance use. While hospitalised for injection drug complications, he received unnecessary …

general practiceemergency medicinemedicationdiagnosticmethadone
QLDhospital2018-07-30

Matthew Douglas McLachlan - Non-inquest findings

28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…

…tient status before prescribing opioids; hospital staff should maintain higher suspicion of drug-seeking behaviour in patients with acknowledged opioid dependency and previous intravenous drug use; coordinated pain mana…

infectious diseasesemergency medicinecommunicationsystemfentanyl
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

…gton, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed was a firearm (l…

emergency medicinetrauma surgerysystemmethamphetamine
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…

general practicepsychiatrydiagnosticcommunicationcannabis
NSWcommunity2017-10-25

Inquest into the death of KE

36y · Male·Shotgun wound to the head

…tors. Lessons include the importance of community mental health service access, encouraging help-seeking behaviour, and recognition that even well-executed de-escalation cannot always prevent suicide in cases of profoun…

psychiatryemergency medicinealcohol
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

…nic symptoms and documented history, citing absence of 'objective evidence of psychosis' and attributing behaviour to substance abuse rather than mental illness; (2) Treating psychiatrists took an inappropriately narrow…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
VIChome2022-12-01

Finding into death of Alicia Maree Little

41y · Female·Multiple injuries

Alicia Maree Little, aged 41, was struck and killed by a motor vehicle driven by her former intimate partner while she was leaving the relationship. The case highlights significant systemic failures in family violence re…

psychologypsychiatrydiagnosticcommunication
QLDhospital2025-07-14

Non-inquest findings into the death of a two year old girl whose family was known to Child Safety

2y · Female·Complications of severe anaemia and SARS-CoV2 (COVID-19) infection

…ed. Key lessons: recognise when parental substance use and psychosocial stressors prevent health-seeking behaviour; seek medical assessment proactively when young children show pallor, feeding difficulties, and developm…

paediatricsemergency medicinediagnosticdelaymethamphetamine
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care
NSWhome2018-07-27

Inquest into the death of Alissa Campbell

26y · Female·Multiple drug toxicity

Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …

general practiceaddiction medicinediagnosticmedicationcodeine
NSW2024-05-21

Inquest into the death of Mohamed Warwar

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

35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…

psychiatrycardiologycommunicationdiagnosticamisulpride
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

Damian Crump, aged 36, was an intensive care paramedic with Ambulance Tasmania who died by suicide on 23 December 2016 by deliberately consuming fatal quantities of morphine, lignocaine, amiodarone and midazolam stolen f…

paramedicinepsychiatrysystemdelaymorphine
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VIChospital2011-08-16

Finding into death of Lisa Irene Sharp

34y · Female·Hanging with combined effects of ethanol and benzodiazepines

Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a cour…

psychiatryemergency medicinediagnosticcommunicationdiazepam
WA2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…

psychologygeneral medicinediagnosticcommunicationaripiprazole

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