Coronial

562 results for intellectual_disability

TAShospital2018-11-08

Coroner's Finding: Fenton, Timothy John

57y · Male·sepsis and multiple organ failure secondary to aspiration pneumonia

Timothy Fenton, a 57-year-old intellectually disabled man on antiepileptic medications, developed a small bowel ileus after presenting with vomiting and diarrhoea. Following emergency laparotomy, his nasogastric tube was…

emergency medicinegeneral surgeryproceduralcommunicationsodium valproate
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

A 37-year-old man died in a deliberate head-on motor vehicle collision three days after his partner died from metastatic cancer. He was the sole carer for his 7-year-old son with autism and intellectual disability. The c…

psychiatrygeneral practicecommunicationdelaymirtazapine
NSWhome2017-11-16

Inquest into the death of Sandra Deacon

59y · Female·blunt force head trauma

Sandra Deacon, aged 59, died from blunt force head trauma inflicted by multiple axe blows to the head by Garry Weigand on 30 September or 1 October 2014 at Budgewoi, NSW. This was a homicide case. Key clinical and system…

forensic medicinepsychiatrysystemantipsychotic medication
VIChospital2023-04-27

Finding into death of Gary Ronald Burgess

59y · Male·Massive aspiration in the setting of intubation following complications of sever…

A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, t…

psychiatrygeneral medicinesystemcommunicationclozapine
NTcommunity2022-05-20

Inquest into the death of Reginald Roy

16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis

Reginald, a 16-year-old Aboriginal boy with first episode psychosis, intellectual disability, and fetal alcohol spectrum disorder, was admitted to the Youth Inpatient Unit and improved significantly with inpatient care. …

psychiatrypaediatricscommunicationsystemaripiprazole
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

A 7-year-old boy died in a head-on motor vehicle collision after his father deliberately drove their newly purchased car into an oncoming truck. The father had recently experienced severe stress following his partner's d…

paediatricspsychiatrycommunicationsystemmirtazapine
VICaged care2013-11-21

Finding into death of Ivo John Martinov

58y · Male·Unascertained causes

A 58-year-old man with treatment-resistant schizophrenia living in aged care died suddenly 30 minutes after receiving his evening clozapine dose. Although post-mortem toxicology detected a potentially toxic clozapine lev…

psychiatrygeneral practicesystemclozapine
VICcommunity2021-10-01

Finding into death of Stuart Anthony Wills

45y · Male·Aspiration of food bolus, with cerebral palsy as contributing factor

Stuart Wills, a 45-year-old man with cerebral palsy and severe dysphagia, died from aspiration of a food bolus while receiving meal assistance at a supported accommodation facility. Prior to his death, a speech pathologi…

speech pathologyemergency medicineproceduraladrenaline
VIC2018-10-24

Finding into death of Sydney Dale Stanfield

55y · Male·Aspiration pneumonia arising as a consequence of severe acquired brain injury

Sydney Dale Stanfield, 55, died from aspiration pneumonia secondary to severe acquired brain injury sustained in childhood. He resided in a disability accommodation service group home and had multiple comorbidities inclu…

palliative caregeneral practicesystemamoxicillin
VICaged care2022-12-12

Finding into death of Lorraine Earl

71y · Female·Complications of cerebral palsy

Lorraine Earl, aged 71, died from complications of cerebral palsy at Wantirna Hospital following a palliative care pathway initiated after severe dysphagia developed during a hospital admission. The Disability Services C…

palliative caregastroenterologycommunicationsystem
VICaged care2022-07-06

Finding into death of Catherine Ann Collier

51y · Female·Aspiration in the setting of end stage down syndrome

Catherine Ann Collier, a 51-year-old woman with Down syndrome, end-stage hydrocephalus, and severe dysphagia, died from aspiration pneumonia following a choking episode while eating. The Disability Services Commissioner …

neurologyspeech pathologysystemcommunicationsodium valproate
VIC2023-07-19

Finding into death of Angela Cuthbert

59y · Female·complications of abscesses following dental extraction, in a woman with cerebral…

Angela Cuthbert, a 59-year-old woman with severe cerebral palsy and dysphagia, died from complications of abscesses following extraction of all 14 teeth under general anaesthetic. Surgery occurred 20 June 2022; she devel…

oral and maxillofacial surgerydentistrycommunicationsystem
VIChospital2013-12-09

Finding into death of JM

17y · Female·Combined Drug Toxicity (heroin, alprazolam and diazepam)

A 17-year-old female with complex mental health and substance use disorders died from combined drug toxicity (heroin, alprazolam, and diazepam) following release from youth detention. Despite extensive involvement from d…

psychiatryaddiction medicinecommunicationsystemheroin
NSW2011-08-19

Coroner's Finding: Terry Griffiths

21y · Male·Suicide by hanging

A 21-year-old Aboriginal man with schizophrenia and depression died by suicide in prison custody. Key clinical failures included: (1) inadequate mental health assessment by Dr S.—45-minute screening reviewing only one of…

psychiatrydiagnosticmedicationresperidone
NSWhome2015-07-30

Inquest into the death of Phillip Buckley

39y · Male·combined drug toxicity

Phillip Buckley, 39, died from combined drug toxicity involving oxycontin, diazepam, alcohol and venlafaxine. He had been prescribed high-dose oxycontin (40-80mg daily) and diazepam by his GP Dr C. for 12 years without c…

general practicepsychiatrymedicationcommunicationoxycodone
VIChomeNew2026-06-23

Finding into death of Kaylah Veronica Sarah Woollard

25y · Female·Mixed drug consumption (pregabalin, oxycodone, desmethylvenlafaxine, aripiprazol…

Kaylah Veronica Sarah Woollard, age 25, died from mixed drug toxicity in the context of significant natural disease. She had WHO Class III obesity (BMI 94.5), cardiac hypertrophy, and mental health conditions (depression…

general practicepsychiatrycommunicationpregabalin
WAmental health2018-07-16

Inquest into the Death of Stanley KING

45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…

Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…

psychiatryemergency medicinediagnosticmedicationzuclopenthixol
VIChome2025-07-03

Finding into death of Stephanie Rebernik

69y · Female·Effects of fire

Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviour…

occupational therapypsychiatrysystemdelayoxazepam
VIChome2026-03-20

Finding into death of HD S

41y · Female·Multiple injuries from assault

A 41-year-old woman with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerati…

communicationsystemcannabis

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