Coronial
VIChome2025-08-20

Finding into death of GFD

2y · Male·Complications of malnutrition

…s mother, TFC, who had an acquired brain injury, mental health conditions (borderline personality disorder, PTSD, depression), and history of family violence, was unable to adequately provide nutrition and hydration. Whi…

paediatricsforensic medicinesystemcommunication
TAScommunity2020-08-13

Coroner's Finding: Wright, Maria Rebekah

31y · Female·drowning, deliberately self-inflicted with intention of ending life

Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 August 2017. She had been discharged from Royal Hobart Hospi…

psychiatrypsychologyparacetamol
QLDcommunity2021-08-20

Dower, Sarahjane - Non-inquest findings

26y · Female·Neck injury due to stabbing

A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…

psychologypsychiatrydiagnosticcommunicationvenlafaxine
VICmental health2023-09-15

Finding into death of Daylon John Roeton

28y · Male·Hanging

Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…

psychiatryemergency medicinesystemproceduralolanzapam
VIChome2022-10-06

Finding into death of Ozlem Karakoc

34y · Female·Drowning

…tellectual disability, a history of mental illness (depression, bipolar disorder, schizoaffective disorder, PTSD), and had experienced prolonged family violence from Mr Davsanoglu including controlling, emotional, and fi…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VIChome2025-08-21

Finding into death of Ryan Andrew Robinson

31y · Male·Mixed drug toxicity (heroin, bromazolam, metonitazine, protonitazene, methamphet…

Ryan Robinson, a 31-year-old man with longstanding opioid use disorder and complex mental health conditions, died from mixed drug toxicity involving heroin, novel psychoactive substances (nitazenes: metonitazene and prot…

general practiceaddiction medicineheroin
QLDcommunity2015-12-14

Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra

42y · Male·Anthony Young: multiple gunshot wounds to the body and arm; David Young: multipl…

…t. The coroner found the shooting justified and lawful. Key clinical lesson: Anthony had documented complex PTSD and substance abuse but was never formally diagnosed with psychotic illness and had no documented homicidal…

psychiatryforensic medicinediazepam
VIChome2020-01-29

Finding into death of Caitlin-Lei Alaya

44y · Female·Combined drug toxicity (elevated pregabalin, temazepam, oxazepam, ibuprofen, mel…

Caitlin-Lei Alaya, a 44-year-old woman with fibromyalgia, PTSD, depression and suicidal ideation, died from combined drug toxicity (elevated pregabalin, temazepam, ibupro…

general practiceemergency medicinemedicationsystempregabalin
VIChome2025-08-13

Finding into death of Lillian Rose Thomas

21y · Female·Compression of the neck secondary to hanging

…g on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a history of chronic suicidality, self-har…

psychiatrygeneral practicesystemdelayprazosin
TAShome2018-08-31

Coroner's Finding: Green, Paul William

66y · Male·carbon monoxide poisoning due to inhalation of exhaust gases from a lawn mower

Paul William Green, a 66-year-old retired engineer with longstanding depression, anxiety, PTSD, and chronic alcohol abuse, died by intentional carbon monoxide poisoning from a lawn mower exhaust. He had…

psychiatrygeneral practicecommunicationsystemantidepressant medication
VIChospital2024-12-02

Finding into death of S K

25y · Male·Gunshot injury to the head

SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver u…

emergency medicinepsychiatrysystemdelaymethamphetamine
NSW2022-12-15

Inquest into the death of YAKAMURRO - Findings

15y · Male·Neck compression due to hanging

…ht after relocation; and inadequate support for non-Aboriginal foster carers. Yakamurro had complex trauma, PTSD, and intellectual/language difficulties. Years of institutional failures isolated him from family while he …

systemcommunication
QLDmental health2007-06-20

Liddell, Matthew John

28y · Male·hypoxic encephalopathy secondary to hanging

Matthew Liddell, a 28-year-old former Navy serviceman with severe post-traumatic stress disorder and depression following the 1998 HMAS Westralia fire, died by hanging in a psychiatric hospital. He had been admitted on 8…

psychiatryemergency medicinecitalopram
VIChome2026-01-08

Finding into death of L L

34y · Female·Combined drug toxicity (gabapentin, oxycodone, tramadol, diazepam, citalopram, d…

A 34-year-old woman with complex medical history including chronic pain, sleep disorder, anxiety and PTSD died from combined drug toxicity involving gabapentin, oxycodone, tramadol, diazepam, citalopram, desmethyl…

general practicerespiratory medicinesystemcommunicationgabapentin
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

…oroner found no adverse findings against police, but identified Peter's untreated mental health conditions (PTSD, borderline personality disorder, chronic suicidality), substance use, and easy access to a realistic gel b…

emergency medicinetrauma surgerysystemmethamphetamine
VICcommunity2025-08-25

Finding into death of Tracey Ellen Knowles

42y · Female·Unascertained; possibly mixed drug toxicity (heroin and methylamphetamine) or sm…

Tracey Ellen Knowles, aged 42, was found deceased in a vehicle on 19 July 2021 from an unascertained cause. She had a history of heroin use and experienced family violence. Police misidentified her as the 'predominant ag…

forensic medicinetoxicologysystemcommunicationheroin
WAhome2019-05-10

Inquest into the Death of Matthew Neil Hardy TONKIN

24y · Male·bronchopneumonia complicating oxycodone toxicity

Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…

general practicepain medicinediagnosticcommunicationoxycodone
VIChome2024-08-29

Finding into death of Natalie Wilson

33y · Female·neck compression and hanging

… mental health conditions including severe social anxiety, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17 and multiple suicide attempts. She died by hanging on 2 September 2020…

psychiatrypsychologysystemescitalopram
VIChome2024-03-07

Finding into death of Claire Louise Carroll

45y · Female·Neck compression secondary to hanging

…She had complex mental health diagnoses (borderline personality disorder, schizoaffective disorder, complex PTSD) and a history of brother's suicide. The coroner found Barwon Health's management suboptimal: the crisis pl…

psychiatrygeneral practicesystemcommunicationclonazepam
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

A 34-year-old male remandee died by self-inflicted neck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 d…

psychiatryemergency medicinediagnosticsystem

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