Coronial

60 results for medication seeking behaviour

WAhome2016-02-10

Inquest into the Death of Daniel James HALL

26y · Male·Multiple drug toxicity and bronchopneumonia

Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…

anaesthesiaENT surgerycommunicationsystemoxycodone
VIChome2014-06-12

Finding into death of Maree Arthur

45y · Female·Pethidine toxicity

…er found Dr P.' friendship with Ms Arthur clouded his clinical judgment. He failed to recognise signs of medication dependence, including stories about lost/stolen medications—established indicators of addiction. Dr P. n…

general practicepain medicinemedicationdiagnosticpethidine
TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

… creating unsustainable span-of-control ratios (one duty manager responsible for 180+ staff), inadequate medication management and security enabling Crump to steal drugs repeatedly undetected, failure to investigate susp…

paramedicinepsychiatrysystemdelaymorphine
NSWcommunity2017-10-25

Inquest into the death of KE

36y · Male·Shotgun wound to the head

…f negotiators. Lessons include the importance of community mental health service access, encouraging help-seeking behaviour, and recognition that even well-executed de-escalation cannot always prevent suicide in cases o…

psychiatryemergency medicinealcohol
VIChome2023-05-25

Finding into death of Bradley Scott Liefvoort

46y · Male·Opioid toxicity (tapentadol and oxycodone)

…died from opioid toxicity (tapentadol and oxycodone) at home in Dandenong. Over a decade of prescription medication misuse began with ibuprofen for headaches, escalating to opioid dependence following gastrointestinal is…

general practicepain medicinemedicationsystemtapentadol
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

…rescription monitoring) was not yet available, the general practitioners who prescribed Schedule 4 and 8 medications to LI on a one-off basis missed critical opportunities to intervene by checking available resources lik…

general practicepsychiatrymedicationdiagnosticcodeine
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

…tical information about her distress was not communicated to supervising prison officers, and there were medication dispensing errors with her anti-psychotic medications in the weeks preceding her death. The coroner foun…

psychiatrygeneral practicecommunicationsystemzuclopenthixol
VIChospital2021-05-01

Finding into death of Sharni Dee Connolly

37y · Female·Multiple drug toxicity

Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…

general practiceemergency medicinemedicationcommunicationtapentadol
VICaged care2011-05-20

Finding into death of Lena Divola

59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…

…ing Day, Lena was found on the floor vomiting and remained there for 30 hours while staff, believing her behaviour was attention-seeking, failed to intervene despite her history of head injury and anticoagulation. She w…

general practicepsychiatryproceduralcommunicationwarfarin
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

…ver communication between crisis teams and day staff after high-risk calls is essential—Ms S disclosed a medication stockpile and suicidal ideation on 10 May but this was not formally handed over to the next shift; (2) d…

psychiatrygeneral practicecommunicationsystemphentermine
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

…n Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone multipl…

general practicesurgerycommunicationsystemdoxylamine
WAhome2016-02-10

Inquest into the Death of Shayne Andrew BERRY

44y · Male·Combined drug effect (oxycodone and benzodiazepines)

…wo different doctors on the same day (15 and 23 November 2012) at different pharmacies, then misused the medication intravenously in combination with his regular benzodiazepines. He had reduced opioid tolerance following…

general practicepharmacologysystemcommunicationoxycodone
QLDcommunity2022-01-13

Clubb, Monique Irene

24y · Female·Undetermined

Monique Irene Clubb, a 24-year-old with opioid addiction following a serious motor vehicle accident, disappeared on 22 June 2013 after obtaining prescriptions for fentanyl patches and diazepam from a medical centre in Be…

general practiceforensic medicinemedicationdiagnosticfentanyl
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

…me (2020-2021), HC's documented relapse into severe alcohol abuse and unauthorized use of her daughter's medications (particularly clonazepam) in early 2022 prompted placement in hospital then respite care. The removal w…

paediatricspalliative care
VIChospital2011-08-16

Finding into death of Lisa Irene Sharp

34y · Female·Hanging with combined effects of ethanol and benzodiazepines

…er court case, which the team knew was a major stressor; and failure to provide transport home or verify medication access. The coroner found deficiencies in care and assessment.

psychiatryemergency medicinediagnosticcommunicationdiazepam
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

… respiratory infection, diabetes), presented to Logan Hospital after police noted concerning psychiatric behaviour. He was appropriately assessed in the Short Stay Unit, where blood gas analysis revealed critical hypoxe…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

…able for 5 years', omitting May 2020 crisis; Dr H. assessed him without full knowledge of prior suicidal behaviour. After Noah's boating injury (September 2022), Wayne stopped medications. His mental health deteriorated…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

…hile on sick leave from May, she received minimal support from the Court or CSV. She saw multiple doctors seeking rapid solutions but did not disclose a serious suicide attempt. A failed earlier suicide attempt and her …

psychiatrypsychologysystemcommunicationantidepressants
SAcommunity2012-11-15

Coroner's Finding: Edgar Lauren Michelle

28y · Female·Multi-organ failure due to Clostridium perfringens myonecrosis complicating lipo…

Lauren Edgar, a 28-year-old woman, died of multi-organ failure from Clostridium perfringens myonecrosis (gas gangrene) following a liposuction procedure performed by Dr K. on 5 March 2008. She presented to hospital on 8 …

plastic and reconstructive surgerygeneral practicediagnosticcommunicationpanadol/paracetamol

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