Coronial

464 results for substance use history

WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

…n's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adeq…

psychiatryemergency medicinecommunicationsystemmethadone
VIChospital2018-02-28

Finding into death of Samuel Carl Johansen

36y · Male·Multi-organ failure complicating injecting drug use

A 36-year-old man with a 13-year history of schizophrenia and substance abuse was admitted involuntarily to a psychiatric unit on 15 September 201…

psychiatryintensive carecommunicationdelayheroin
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He…

psychiatrygeneral practicediagnosticsystemduloxetine
VIC2010-12-12

Finding into death of David William Macumber

35y · Male·Mixed drug toxicity (alcohol and diazepam)

A 35-year-old man with a history of drug and alcohol addiction died from mixed drug toxicity (alcohol 0.37 g/100mL and diazepam) after bei…

forensic medicinesystemalcohol
VIC2022-03-08

Finding into death of Dylan James Charlton-Smith

25y · Male·Hypoxic ischaemic brain injury due to hanging

… rather than health-based interventions. Mental health assessment did not occur despite his S4 (self-harm history) rating. While staff made vigorous resuscitation efforts, the coroner found the decision to address escap…

psychiatryemergency medicinediagnosticcommunication
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

…psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child was found unresponsive after co-sleeping with her father in a warm bedroom. Multiple SIDS risk f…

paediatricspsychiatrysystemdelay
VIC2013-06-05

Finding into death of Leigh Ronald Bellingham

37y · Male·Toxic effects of heroin in combination with mirtazapine and sertraline

Leigh Ronald Bellingham, a 37-year-old man with a history of depression, suicidality, hepatitis C, and substance abuse, died from toxic effects of heroin in combin…

general practicepsychiatrycommunicationsystemheroin
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

…Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and borderline personality disorder, substance use, and intellectual disability. Criti…

psychiatryemergency medicinediagnosticcommunication
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 Nove…

psychiatryintensive carecommunicationsystempaliperidone
VIChome2020-02-25

Finding into death of Laurie Henry Cartledge

44y · Male·Heroin toxicity in the setting of ischaemic heart disease

…om prison. He had been granted parole despite assessments recommending against it, citing poor compliance history. Within hours of release, he obtained heroin and used it, likely with reduced tolerance after prison abst…

forensic medicineaddiction medicinesystemcommunicationheroin
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

29y · Male·ligature compression of the neck (hanging)

…gnificant adverse childhood events (ACE score of 7+), two previous suicide attempts, and violent criminal history. This missing information compromised all subsequent risk assessments and management decisions, including…

correctional healthpsychiatrysystemcommunication
NSW2018-06-26

Inquest into the death of Glen Russell

32y · Male·asphyxia arising from neck compression from self-inflicted ligature strangulatio…

Glen Russell, 32, died by suicide in Cessnock Correctional Centre while on remand. He had a complex history including childhood sexual assault, schizophrenia diagnosis, heroin use, and recent self-harm episodes. A…

psychiatrygeneral practicediagnosticcommunicationmirtazapine
QLDhome2017-07-26

Richards, Karen Louise

41y · Female·mixed drug and alcohol toxicity

…cal lessons: rapid recognition of altered consciousness and immediate emergency response are critical; drug users and their contacts require education on overdose recognition and first aid; delay in treatment initiation…

psychiatryemergency medicinedelaysystemheroin
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to hi…

psychiatrytoxicologycommunicationdelaymethamphetamine
VICcommunity2018-03-14

Finding into death of C P

59y · Female·Gunshot injuries to the head

…ating pattern of physical and emotional family violence throughout their relationship. CP had experienced abuse since childhood, suffered mental and physical health complications, and became dependent on alcohol. She wa…

psychiatrydiagnosticcommunicationcitalopraam
VIChome2022-08-08

Finding into death of Kim Michelle Cooper

47y · Female·Mixed drug toxicity (pregabalin, oxycodone and mirtazapine)

A 47-year-old woman died from mixed drug toxicity involving pregabalin, oxycodone, and mirtazapine. She had chronic pain, anxiety, and depression, and attended a medical clinic frequently. Over five days before her death…

general practiceaddiction medicinemedicationsystempregabalin
VICmental health2024-02-27

Finding into death of Sidarthan Gajaharan

26y · Male·Craniocervical injuries following a train collision (pedestrian)

Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…

psychiatryrehabilitation medicinecommunicationdelayclozapine
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

…alist child protection units on 16-17 November but lacked resources for emergency accommodation and did not use the afterhours DCSSDS hotline. The family remained disconnected from consistent support. Multiple agencies …

paediatricspsychiatrysystemcommunication
NSWcommunity2023-11-17

Inquest into the death of SB

51y · Male·Stab wounds to the chest

…the outcome. (2) Police should have gathered more detailed information from family members, who knew SB's history and recent self-harm allegations better than anyone. (3) The decision-making and tactical response were a…

psychiatryemergency medicinecommunicationsystemolanzapine
TAShospital2025-08-29

Coroner's Finding: Scott, Nicholas Aaron

26y · Male·shotgun wound of the chest

Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer super…

correctional healthemergency medicineproceduralcommunicationmethamphetamine
120212224

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