Coronial
NSWaged care2014-03-14

Inquest into the death of Sybil ZIMMERMAN

84y · Female·coronary artery thrombosis on a background of multiple co-morbidities including …

…ate and unlikely to cause death in this patient. The family's accusations appeared based on coincidence (drowsiness following morphine administration) without objective medical evidence of overdose or causation.

geriatric medicinegeneral practicemorphine
VIC2022-06-03

Finding into death of Micky Craig Revera

40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…

…leared for police custody. In prison, he presented with opioid withdrawal symptoms, minimal oral intake, drowsiness, and difficulty mobilising. Despite appropriate medical and psychiatric assessments over four days, no c…

emergency medicineforensic medicinediagnosticcommunicationheroin
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

…ecognise clinical deterioration despite clear family observations of respiratory depression and profound drowsiness; and prescription of slow-release oxycodone (OxyContin) in combination with fast-acting opioids without …

neurologyemergency medicinediagnosticmedicationfentanyl
QLDcommunity2008-04-24

Schibrowski, John Malcolm

Male·injuries sustained in a motor vehicle incident involving excessive speed on a be…

….287% and was taking antidepressants (Oxazepam and Clomipramine), which in combination would have caused drowsiness, blurred vision and in-coordination, rendering him incapable of driving. He likely died within 3 minutes…

diagnosticsystemalcohol
WAcommunity2025-08-11

Inquest into the Suspected Death of Simon Brian HARRINGTON

34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…

Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…

psychiatryemergency medicinecommunicationquetiapine
QLDworkplace2016-02-29

MJP - Non-inquest findings

27y · Female·Pentobarbitone toxicity

…oxetine (Cymbalta), an SNRI with warnings against alcohol use due to risk of liver damage, dizziness and drowsiness. Her GP found no suicidal risk at her last consultation 2 weeks prior. Clinical lessons: alcohol signifi…

general practicepsychiatrysystemcommunicationpentobarbitone
QLDcommunity2007-10-12

Zupp, Jason John

25y · Male·Hypovolemic shock and anoxia due to massive trauma to the rib cage and rupture o…

Jason Zupp, a 25-year-old truck driver, died in a motor vehicle crash after his Mack truck overturned approximately 16km north of Taroom on the Leichhardt Highway. The coroner found that he fell asleep while driving afte…

forensic medicineoccupational and environmental healthsystemcommunication
SAhome2010-09-30

Coroner's Finding: Infant Co-Sleeping

Female·Multiple: undetermined consistent with overlaying (Naomi Kade); undetermined pos…

This inquest examined five infant deaths (aged 1 month to 10 months) occurring between July 2007 and November 2008, all involving co-sleeping with adults. Deaths were attributed to undetermined causes, possible overlayin…

forensic medicinepaediatricsamitriptyline
NSWmental health2014-08-08

Inquest into the death of Josephine LAMBERT

44y · Female·natural causes, possibly a cardiac arrhythmia

…er death. No signs of clozapine toxicity were observed clinically; she remained stable without excessive drowsiness or vital sign abnormalities. The coroner concluded the death was likely due to natural causes, specifica…

psychiatryforensic medicineclozapine
NSWcommunity2009-05-28

Coroner's Finding: Sarah Anne Rawson

25y · Female·Multiple injuries sustained from accidental fall from cliff edge

Sarah Anne Rawson, a 25-year-old woman recovering from a serious road traffic accident that had left her with restricted mobility, died when she fell approximately 70 metres from a cliff edge at Hargraves Lookout in the …

occupational therapypharmacologysertraline
QLDcommunity2009-05-14

Maczkowiack, Peter James and Mackowiack, Pauline Anne

Male·Multiple injuries from motor vehicle trauma (head-on collision with truck)

Peter and Pauline Maczkowiack were killed in a head-on collision with a truck on the Bruce Highway near Marlborough, Queensland on 27 December 2006. The truck driver, Donald MacFarlane, had epilepsy. The coroner found th…

occupational and environmental healthneurologysystemcommunicationphenytoin
VICaged care2016-02-08

Finding into death of Leslie Frederick Alexander

77y · Male·Subarachnoid and subdural haemorrhage post head trauma secondary to a fall

…nd neurological observations were ceased. On 30 March morning, Mr Alexander deteriorated with confusion, drowsiness, and inability to follow commands. He was transferred to hospital where CT imaging revealed acute intrac…

general practiceemergency medicinediagnosticcommunication
SAhome2002-05-23

Coroner's Finding: DAVIES Nicole Memory Faye

17y · Female·mixed drug toxicity

…hadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet received her final methadone dose while already affected by previous m…

general practiceaddiction medicinediagnosticmedicationmethadone
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…

general practicepsychiatrydiagnosticdelaylithium
QLDcommunity2018-06-05

Smit, Bernardus Johan

50y · Male·Head injuries due to motor vehicle accident

…uded codeine toxicity did not cause loss of consciousness. The driver likely experienced sudden fatigue, drowsiness or undiagnosed cardiac event. Key lessons: medical practitioners should assess fitness to drive in patie…

general practicehaematologysystemparacetamol/codeine
WAcommunity2010-12-20

Inquest into the Death of Sweeny

20y · Female·Multiple injuries followed by incineration as a result of single motor vehicle c…

Annemarie Sweeny, a 20-year-old Patient Care Assistant at Narembeen Regional Hospital, died in a single-vehicle motor vehicle collision on 8 November 2008 after completing a night shift. She had worked multiple consecuti…

occupational and environmental healthsystemdelaysertraline
NSWhospital2023-09-11

Inquest into the death of TE

26y · Female·multiple blunt force injuries from fall from height; significant contributing co…

A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …

psychiatryemergency medicinediagnosticcommunicationpregabalin
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
SAhome2004-11-18

Coroner's Finding: CUNNINGHAM Tracey-Lee

26y · Female·morphine toxicity complicated terminally by bronchopneumonia

…mately 7.3 grams over the final month. Despite clear signs of intoxication on 21-22 May (slurred speech, drowsiness, incoordination), morphine continued to be prescribed. The coroner found the prescription of large quant…

general practiceneurologymedicationdiagnosticmorphine
SA2007-07-12

Coroner's Finding: SANSBURY Colin Craig

24y · Male·diffuse hypoxic ischaemic encephalopathy due to hanging

Colin Craig Sansbury, 24-year-old Aboriginal man, died by hanging while in police custody at Elizabeth Police Station. Critical failures in care included: (1) Inadequate psychiatric assessment at Lyell McEwin Hospital—he…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.