multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
53y · Male·severe burns
Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-immolate due to distress about power cuts at h…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…
25y · Female·Chest injuries due to fall from height
Two psychiatric inpatients (SH, 25-year-old female; AW, 24-year-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite…
29y · Female·gunshot wound to the abdomen
Joyce Gladis Clarke, a 29-year-old Aboriginal woman, was fatally shot in the abdomen by First Class Constable Wyndham while police responded to a call about a person carrying a knife in a Geraldton street. Clarke had bee…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…
Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…
16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis
Reginald, a 16-year-old Aboriginal boy with first episode psychosis, intellectual disability, and fetal alcohol spectrum disorder, was admitted to the Youth Inpatient Unit and improved significantly with inpatient care. …
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …
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