50 results
42y · Male·methadone toxicity
Andrew Gilbertson, a 42-year-old man with bipolar disorder and substance use disorder, died from methadone toxicity while in custody at Long Bay Correctional Centre. He was not enrolled in opioid substitution therapy but…
33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…
A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…
19y · Male·Hanging
LAK, a 19-year-old Aboriginal man, died by suicide at a community rehabilitation facility after a complex mental health journey involving forensic orders and psychosis. Key clinical lessons include: recognising vulnerabi…
1y · Male·methadone toxicity
Phoenix Hemmings, a 14-month-old child, died from methadone toxicity on 31 March 2015. He was found unresponsive at home after falling asleep on a sofa next to his mother, while his mother's partner (on a methadone opioi…
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. Despite this psychiatric and substance abuse history, he hel…
41y · Female·unable to determine
Carley Metcalfe, aged 41, was found deceased in the Brunswick River in November 2017, three weeks after disappearing. She had presented to Lismore Base Hospital on 1-2 November 2017 with acute psychosis related to schizo…
Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…
Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …
46y · Male·blunt force injuries from motor vehicle collision with a tree
A 46-year-old Aboriginal man died by suicide following a motor vehicle collision with a tree while being pursued by police responding to a welfare check. He had a complex history of depression, amphetamine addiction (ice…
47y · Male·acute alcohol intoxication
Julian Horne, 47, died from acute alcohol intoxication at home after 11 hospital admissions in 6 weeks during a severe binge relapse. He had lifelong struggles with alcohol, depression and anxiety, previously tried multi…
26y · Male·multiple injuries from fall from height
A 26-year-old man with schizophrenia was discharged from mental health inpatient care on a community treatment order without meeting his allocated case manager, confirmed accommodation, or drug and alcohol intervention. …
45y · Male·Shotgun wound to the head
XY, a 45-year-old Aboriginal man, died from a self-inflicted gunshot wound during a police response to a domestic violence incident. He had been struggling with depression, grief, alcohol and methamphetamine use for year…
34y · Male·Methadone toxicity, with coronary artery atherosclerosis as a significant contri…
Ivan Mikic, a 34-year-old prisoner at Wellington Correctional Centre, died from methadone toxicity on 3 November 2015. The methadone was not prescribed to him and was most likely obtained through diversion by another inm…
Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…
Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…
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 …
22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree
22-year-old Benjamin Gilligan died in a motor vehicle crash while fleeing psychiatric care, having been recently diagnosed with methylamphetamine-induced psychosis. Key clinical issues identified: (1) communication break…
46y · Male·Complications of chronic alcoholism and hypertension
Craig Leishman, 46, died from complications of chronic alcoholism and hypertension. He had a 10-year history of heavy alcohol use, liver failure (identified February 2016), and completed rehabilitation. Two weeks before …
44y · Female·Acute bronchopneumonia complicating multi-drug toxicity (alprazolam, opiates, be…
Meaghan Gardner, a 44-year-old woman with a history of respiratory problems, pneumonia, schizophrenia, and substance abuse, died from acute bronchopneumonia complicated by multi-drug toxicity (alprazolam, opiates, benzod…
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 after approximately three weeks. The exact date an…
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