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VIChome2023-07-28

Finding into death of Jackson Desmond David Stawicki

24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm

Jackson Stawicki, 24, died from haemorrhagic shock following a sharp force injury to his left arm while intoxicated with multiple illicit substances. He presented to the ED three times within 24 hours (4-5 September 2020…

emergency medicinepsychiatrycommunicationsystemflualprazolam
VIChome2023-07-27

Finding into death of Mr A

31y · Male·Hanging

Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …

psychiatrygeneral practicesystemcommunicationmethamphetamine
TAScommunity2023-07-24

Coroner's Finding: de-identified FR

27y · Female·carbon monoxide intoxication due to voluntary and intentional inhalation of exha…

A 27-year-old woman with a lengthy history of depression, anxiety, and previous suicide attempts died by carbon monoxide poisoning. She was referred to mental health crisis services on 4 July 2020 with documented suicida…

psychiatrygeneral practicecommunicationsystem
TAShome2023-07-24

Coroner's Finding: QD de-identified

45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…

QD, a 45-year-old woman with significant comorbidities including obesity, obstructive sleep apnoea, COPD, depression, and substance abuse history, died from mixed drug and alcohol intoxication. Toxicology revealed toxic/…

general practicepsychiatrydelaysystemtapentadol
NSWhospital2023-07-21

Inquest into the death of Ziad Hamawy

51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …

Ziad Hamawy, a 51-year-old man with chronic schizophrenia and polysubstance use disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019…

psychiatryemergency medicinediagnosticcommunicationheroin
NSW2023-07-21

Inquest into the death of Reuben Button

34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…

Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…

psychiatrygeneral practicediagnosticsystembuvidal
NSW2023-07-20

Inquest into the death of Jean-Louis Langlois

50y · Male·Immersion, with alcohol intoxication and doxepin toxicity being significant fact…

Jean-Louis Langlois, a 50-year-old French-Australian man with significant mental health issues, alcohol dependence, and chronic social difficulties, was found deceased on Wanda Beach in January 1997. He died from immersi…

forensic medicinepsychiatrysystemdoxepin
VIChospital2023-07-19

Finding into death of Daryl William Nioa

74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…

A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …

emergency medicineneurosurgerydiagnosticdelayclonazepam
WAhome2023-07-14

Inquest into the Death of Matthew James WORTHINGTON

Male·Gunshot injury to the head

Matthew Worthington died from a self-inflicted gunshot wound to the head during a 21-hour police siege at his home in Bayswater, Western Australia, on 24 November 2020. He was experiencing a relationship breakdown, had r…

emergency medicineintensive caremethamphetamine
NSWprison2023-07-14

Inquest into the death of GS

43y · Male·Hanging

GS, a 43-year-old man with complex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in Goulburn Correctional Centre after 183 days in custody. The critical fail…

psychiatrygeneral practicediagnosticcommunicationsertraline
NSW2023-07-06

Inquest into the death of RRC

26y · Male·hanging, intentionally self-inflicted

A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…

psychiatrycorrectional healthcommunicationdocumentation
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
NSWhome2023-07-05

Inquest into the death of JY

5y · Male·multiple stab wounds

A 5-year-old boy died from multiple stab wounds inflicted by his father during an acute psychotic episode. The father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deteri…

psychiatrygeneral practicecommunicationsystemrisperidone
TAS2023-06-30

Coroner's Finding: Barron Rickie Underwood

61y · Male·hanging, the result of actions undertaken by the deceased alone, voluntarily and…

Rickie Underwood Barron, aged 61, died by hanging in Tasmania's Ron Barwick Minimum Security Prison on 10-11 January 2022. He had been incarcerated since 2019 for sexual offences and received appropriate medical care for…

psychiatrycorrectional healthsystemantidepressant medication
SAmental health2023-06-30

Coroner's Finding: Williamson, Vaughan Weston

41y · Male·undetermined

Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neuropathological …

psychiatryemergency medicineolanzapine
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…

psychiatrygeneral practicesystemmethamphetamine
ACThome2023-06-28

Inquest into the death of LIAM FLETCHER MOORS

46y · Male·Acute purulent pericarditis as a consequence of an infected injection, in the co…

A 46-year-old man with schizophrenia and long-standing methamphetamine use died of acute purulent pericarditis secondary to a self-administered infected injection. He was subject to a Psychiatric Treatment Order at the t…

psychiatryforensic medicinemethamphetamine
ACTmental health2023-06-27

Inquest into the death of MERREN ELIZABETH BARTLEY

67y · Female·ischaemic heart disease

Merren Elizabeth Bartley, a 67-year-old woman with schizophrenia managed with clozapine and multiple comorbidities including coronary artery disease, died of ischaemic heart disease while an inpatient at a mental health …

psychiatrycardiologyclozapine
VICmental health2023-06-22

Finding into death of Catherine Ann Williamson

58y · Female·plastic bag asphyxia

Catherine Williamson, a 58-year-old voluntary psychiatric inpatient, died from plastic bag asphyxia at a private mental health facility. She had schizo-affective disorder and a history of suicide attempts. Despite return…

psychiatrysystemcommunication
VICmental health2023-06-22

Finding into death of Veronika (Veronica) Anastasia Kouros

31y · Female·Plastic bag asphyxia

31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospit…

psychiatrygeneral practicesystemproceduralquetiapine

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