Coronial

67 results for central nervous system depression

VIChome2013-10-01

Finding into death of Dion Heather

38y · Male·Aspiration of Gastric Content and Combined Drug Toxicity (Methadone, Benzodiazep…

…pounding the depressant effects of multiple CNS-suppressing medications. The coroner identified a critical systemic issue: take-away methadone doses were dispensed with minimal supervision despite being Schedule 8 drugs.…

addiction medicinegeneral practicesystemdelaymethadone
VIChome2021-12-17

Finding into death of KF Z

25y · Male·Combined flualprazolam and alcohol toxicity

…feit alprazolam. The combination of benzodiazepines with alcohol produces dangerous additive respiratory depression. The coroner recommends Victorian health authorities consider harm reduction strategies including drug c…

forensic medicinetoxicologysystemflualprazolam
VIChome2021-07-27

Finding into death of Daniel Joseph Herbert

37y · Male·Combined drug toxicity (methadone, fentanyl, diazepam and pregabalin)

Daniel Joseph Herbert, aged 37, died from combined drug toxicity involving methadone, fentanyl, diazepam and pregabalin. He had a 17-year history of opioid dependence stemming from prescription OxyContin for a work-relat…

general practiceaddiction medicinecommunicationsystemmethadone
VIChome2024-03-18

Finding into death of C J

44y · Female·Mixed drug toxicity (buprenorphine, ketamine, diazepam, fluvoxamine and lacosami…

A 44-year-old female veterinarian died from mixed drug toxicity involving buprenorphine, ketamine, diazepam, fluvoxamine and lacosamide. She had a 18-19 year history of opioid addiction, initially using heroin recreation…

addiction medicinepsychiatrybuprenorphine
VIChome2012-07-18

Finding into death of Joshua Meloury_Kaup

15y · Male·Mixed drug toxicity (morphine, 7-aminoclonazepam, fluoxetine, sertraline)

…ting his grandmother's medications (morphine, benzodiazepine, sertraline) while fluoxetine remained in his system. He had been placed in his grandmother's care on 10 May 2010 following secure welfare placement. On 12 May…

paediatricspsychiatrysystemcommunicationmorphine
TAScommunity2024-04-17

Coroner's Finding: QR

42y · Female·Drowning due to combined drug (tramadol, venlafaxine, diazepam, quetiapine and c…

A 42-year-old woman with bipolar disorder, chronic pain, and emphysema died by drowning while scuba diving in shallow water after a 3-year hiatus from diving. She was taking multiple CNS-depressant medications (tramadol,…

general practicepsychiatrycommunicationtramadol
TAScommunity2019-09-09

Coroner's Finding: Wilson, Jacob Leigh

27y · Male·chest and abdominal injuries from single motorcycle crash

…ne, pregabalin) and illicit substances including opium alkaloids, indicating poppy tea consumption. These central nervous system depressants impaired coordination, reflexes, and perception. The motorcycle had worn tyres…

general practicepsychiatrycommunicationdiazepam
VIChome2017-06-20

Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…

…ividual prescriber at fault but highlighted the absence of real-time prescription monitoring as a critical system gap enabling preventable polypharmacy deaths.

general practiceneurosurgerysystemcommunicationoxycodone
TAShome2020-05-19

Coroner's Finding: Adams, Christopher Neil

31y · Male·mixed prescription drug toxicity (methadone, fluvoxamine, tramadol, mirtazapine …

…epressants. With low tolerance to methadone, obesity, and severe heart disease, he died from respiratory depression and aspiration. The coroner emphasised that adherence to Tasmanian methadone prescribing guidelines (TOP…

general practiceemergency medicinesystemmethadone
QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

… Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. He had been assaulted in custody and was on mu…

psychiatrycorrectional healthsystemdiazepam
QLDhome2017-07-26

Richards, Karen Louise

41y · Female·mixed drug and alcohol toxicity

Karen Louise Richards, 41 years old, died from mixed drug and alcohol toxicity on 11 January 2014. She had consumed heroin (evidenced by 6-MAM metabolite), alcohol, benzodiazepines, and other prescription medications. He…

psychiatryemergency medicinedelaysystemheroin
TAShome2020-11-09

Coroner's Finding: Spencer, Melissa Mary

54y · Female·mixed drug toxicity

A 54-year-old nurse with chronic pain from a 1990 back injury died from mixed drug toxicity involving morphine, codeine, doxylamine and nitrazepam. She was prescribed multiple CNS depressants for years despite being desi…

general practicepain medicinemedicationsystemmorphine
ACThome2018-12-20

Inquest into the death of Lesley Kaye Hasleby

61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…

A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindic…

general practicerespiratory medicinediagnosticcommunicationdosulepin
TAShome2020-05-14

Coroner's Finding: Cashion, Brett Matthew

48y · Male·combined drug intoxication from morphine and quetiapine

Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphine. He was receiving daily Subutex in Tasmania from …

general practicepain medicinecommunicationsystemmorphine
VIChome2026-02-17

Finding into death of Laurence Mark O'brien

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

…ping. Three general practitioners failed to check SafeScript (Victoria's real-time prescription monitoring system) before prescribing monitored medications, perpetuating his addiction cycle. His regular treating team app…

general practicepsychiatrymedicationsystemtapentadol
VICmental health2019-10-29

Finding into death of Elizabeth Honor Ewart

55y · Female·Unascertained

Elizabeth Ewart, aged 55, died at The Melbourne Clinic on 27 February 2017. She had bipolar disorder, anxiety and schizoaffective disorder. After administering PRN Olanzapine 2.5mg at 4:35pm for agitation, Nurse Cook was…

psychiatryemergency medicinecommunicationsystemolanzapine
ACThospital2016-12-16

AN INQUEST INTO THE DEATH OF PAUL FENNESSY

21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…

…harmacy hours before death; and absence of any safety planning for a homeless, highly intoxicated patient. System-level failures included inability to detect prescription drug misuse across multiple providers, lack of re…

emergency medicinepsychiatrycommunicationsystemmethadone
VICcommunity2015-01-20

Finding into death of Peter Oelfke

48y · Male·Haemophilus influenzae bronchopneumonia in the setting of alcohol and methadone …

Peter Oelfke, a 48-year-old man with alcohol and opioid dependence, died from haemophilus influenzae bronchopneumonia complicated by alcohol and methadone toxicity. He had no fixed address and lived in a tent. His GP pre…

general practiceforensic medicinemedicationsystemmethadone
VIChospital2021-09-21

Finding into death of AH

37y · Male·Mixed Drug Toxicity (Oxycodone, Quetiapine, Pregabalin and Clonazepam)

A 37-year-old man died from mixed drug toxicity (oxycodone, quetiapine, pregabalin, clonazepam) after ingesting unknown quantities of his own medications in an ED. He presented with trauma symptoms four days post-motor v…

emergency medicinetoxicologydiagnosticcommunicationoxycodone
VIChome2026-04-17

Finding into death of Harrison William Ladd

25y · Male·Combined drug toxicity

Harrison William Ladd, 25, died from combined drug toxicity involving clonazepam, dexamphetamine, codeine, diazepam and pholcodine. He had complex mental health and substance use disorder requiring specialist addiction c…

general practicepsychiatrymedicationcommunicationclonazepam

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