Coronial
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TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
WA2024-11-15

Inquest into the death of Kingsley Dean Garlett

32y · Male·ligature compression of the neck (hanging) in a man with methadone and methylamp…

Kingsley Garlett, aged 32, died by hanging in a maximum security prison cell on 31 July 2022. The evidence indicates his death was an impulsive response to relationship conflict with his partner revealed through prison p…

psychiatrypsychologysystemdelaymethadone
QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…

psychiatryemergency medicinecommunicationsystemmethamphetamine
VIChospital2024-10-07

Finding into death of Danielle Julie Kaye Thomson

41y · Female·Neck compression and hanging

Danielle Thomson, a 41-year-old woman with complex medical and mental health conditions including cervical dystonia, bipolar disorder, borderline personality disorder, chronic pain, and alcohol use disorder, died by suic…

psychiatryaddiction medicinecommunicationsystembuprenorphine
NSW2024-09-17

Inquest into the death of Robert Phair

37y · Male·Cardiomegaly giving rise to lethal cardiac arrhythmia in the setting of drug tox…

37-year-old Robert Phair died in Parklea Correctional Centre from cardiomegaly causing lethal cardiac arrhythmia in the setting of drug toxicity. He was placed in detoxification requiring four-hourly clinical observation…

addiction medicineemergency medicinediagnosticcommunicationheroin
SAhome2024-09-13

Coroner's Finding: Sulley, Matthew Wade

46y · Male·neck compression due to hanging

Matthew Wade Sulley, aged 46, died by hanging while on home detention under Department for Correctional Services supervision. He had a significant psychiatric history including previous suicide attempt by hanging (1997),…

forensic medicinepsychiatrycommunicationsystemmethamphetamine
SAhome2024-09-02

Coroner's Finding: Woods, Travis John

36y · Male·hanging

Travis John Woods, 36, died by hanging while on home detention bail in South Australia on 10 February 2021, classified as a death in custody. He had a long history of methamphetamine dependence, unresolved trauma, PTSD, …

forensic medicinegeneral practicemethamphetamine
NSWcommunity2024-08-13

Inquest into the death of Brett Walker

37y · Male·multiple gunshot wounds

Brett Walker, 37, was shot by police on 9 July 2022 after a domestic violence incident 23 days post-release from prison. He had long-standing drug addiction and mental health issues including paranoid ideation, particula…

psychiatryaddiction medicinesystemcommunicationcrystal methamphetamine
NSWhome2024-08-09

Inquest into the death of Linus Phillips

65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…

Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…

general practiceaddiction medicinediagnosticmedicationmethadone
QLDhome2024-07-22

Non-inquest findings into the domestic violence related death of a First Nations woman

31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…

A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…

general practiceobstetricscommunicationsystemmethamphetamine
VIC2024-07-01

Finding into death of Joshua Steven Kerr

32y · Male·methylamphetamine toxicity

Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…

emergency medicinepsychiatrydiagnosticcommunicationmethamphetamine
QLD2024-06-18

Inquest into the deaths of Shiralee Deanne Tilberoo and Vlasta Wylucki

Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…

Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…

cardiologyaddiction medicineproceduralcommunicationdiazepam
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
VIChome2024-05-24

Finding into death of L I

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

LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…

general practicepsychiatrymedicationdiagnosticcodeine
VICcommunity2024-05-15

Finding into death of Denise Lucina Roberts

63y · Female·Combined features of bronchopneumonia, emphysema and ischaemic heart disease on …

A 63-year-old woman with depression, anxiety, liver cirrhosis, and chronic drug use died from bronchopneumonia, emphysema, and ischaemic heart disease following a prolonged lie on the ground with hypothermia. She missed …

general practiceaddiction medicinecommunicationsystemdiazepam
VIChome2024-05-14

Finding into death of PJQ PJQ

18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)

PJQ was an 18-year-old in state care who died from multidrug toxicity (GHB, amphetamines, benzodiazepines) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and…

paediatricspsychiatrysystemdelayGHB
NSWhome2024-03-26

Inquest into the death of MO

6y · Unknown·methadone toxicity

A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…

addiction medicinepaediatricsdiagnosticcommunicationmethadone
NSWhome2024-03-21

Inquest into the death of Brandon Rich

29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…

Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…

cardiologypsychiatrycommunicationsystemmethamphetamine
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
VIChome2024-03-13

Finding into death of S L

38y · Male·Mixed drug toxicity including metonitazene

A 38-year-old man with a long history of substance use, depression, anxiety and ADHD died from mixed drug toxicity involving metonitazene. He believed he was injecting heroin but had unknowingly obtained metonitazene (a …

psychiatrygeneral practicemetonitazene

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