Coronial

213 results for medication dependence

VIChome2026-01-08

Finding into death of L L

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

…ribers and dispensers despite 66 system notifications in the year before death; incomplete disclosure of medications by the patient to clinicians; lack of real-time monitoring of gabapentin (not yet on SafeScript); and u…

general practicerespiratory medicinesystemcommunicationgabapentin
QLD2011-10-14

Death of a prisoner

34y · Male·Asphyxia consistent with plastic bag asphyxia

… a psychiatric history with prior suicide attempts and was on olanzapine. He ceased taking antipsychotic medication 14 days before death; clinical review by a psychologist 6 days later found no signs of psychosis or depr…

psychiatrycorrectional healthsystemdelayolanzapine
VIChome2016-06-06

Finding into death of Jim Zanis

33y · Male·Mixed drug toxicity (heroin, buprenorphine and benzodiazepines)

…to restrict access. Critical clinical lessons: (1) Multiple prescribers failed to identify or act on his medication-seeking behaviour despite warnings from his mother; (2) He declined hospital admission after an overdose…

general practiceemergency medicinediagnosticcommunicationheroin
VIChome2020-06-12

Finding into death of Daniel Isaac Semple

39y · Male·Multiple drug toxicity (methadone, diazepam, oxazepam, carbamazepine, levetirace…

A 39-year-old man with epilepsy and opioid dependence died from multiple drug toxicity involving methadone, benzodiazepines (diazepam, oxazepam), antiepilepti…

general practiceaddiction medicinediagnosticmedicationmethadone
QLDhome2018-05-21

House, William John; White, Vanessa Joan; Smith, Jodie Anne and Milne, Daniel Keith

Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…

…y prescribers, and insufficient clinical education. Contributing factors: inadequate assessment for drug dependence; prescribing without real-time access to patient's dispensing history; prescription oversight gaps betwe…

general practicepain medicinediagnosticmedicationfentanyl
QLDhome2010-06-09

Edwards, Peeta Louise Josephine

32y · Female·Opiate toxicity; toxic combination of morphine and codeine causing respiratory d…

… The coroner criticised the inadequate police investigation: no thorough search was conducted initially, medication collection was delayed 14 months, and the puncture mark was not documented in the police report despite …

general practicepsychiatrysystemdelaymorphine
VICcommunity2016-02-12

Finding into death of ARCHIVE Finding Hunter Joseph Stewart

27y · Male·Combined drug toxicity (heroin, methadone, diazepam and amphetamines)

Hunter Joseph Stewart, a 27-year-old with major depressive disorder and alcohol dependence, was admitted to St Vincent's Acute Inpatient Service following police custody for public intoxication. …

psychiatryaddiction medicinecommunicationsystemheroin
VICcommunity2014-07-16

Finding into death of Shannon James Lees

23y · Male·multidrug overdose including tramadol and methadone

Shannon Lees, a 23-year-old with schizoaffective disorder and polysubstance abuse, absconded from a mental health rehabilitation unit and died from multidrug overdose involving tramadol and methadone (not prescribed to h…

psychiatryaddiction medicinesystemmethadone
VIChome2015-07-24

Finding into death of James Stewart Dougan

32y · Male·Mixed drug toxicity (codeine, methadone, alprazolam, diazepam) in a man with cor…

James Dougan, 32-year-old man with longstanding polysubstance abuse, died from mixed drug toxicity (codeine, methadone, alprazolam, diazepam) complicated by severe coronary artery atherosclerosis. He engaged in prescript…

general practiceaddiction medicinemedicationcommunicationalprazolam
NSWhome2022-03-30

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY

38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…

…ssons include: inadequate communication between Stacey's psychiatrist and general practitioner regarding medication (Alprazolam dose increasing above authorized limits, concurrent Tramadol prescription not discussed); su…

psychiatrygeneral practicemedicationcommunicationalprazolam
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

… multiple neurosurgeries and was prescribed opioids and benzodiazepines. He developed addiction to these medications, engaged in 'doctor shopping' across multiple practices, and robbed pharmacies to obtain drugs. Followi…

neurosurgerypsychiatrycommunicationsystemfentanyl
NSWcommunity2021-06-08

Inquest into the death of Zhong Liu

54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…

…tient overdosed significantly); physiological stress from psychosis and physical restraint; and possible medication miscommunication. Critical clinical lessons: (1) the combination of doxepin and venlafaxine requires car…

psychiatrygeneral practicemedicationcommunicationdoxepin
NSWcommunity2014-06-27

Inquest into the deaths of Christopher SALIB, Nathan ATTARD and Shamsad AKHTAR

Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…

…ti-drug toxicity). All died from lethal combinations of benzodiazepines, opioids, and other prescription medications obtained through multiple doctors ('doctor shopping'). Key failures included: lack of real-time prescri…

general practiceemergency medicinediagnosticmedicationalprazolam
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
NSWhospital2023-09-11

Inquest into the death of TE

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

…r the same day. Expert evidence indicates she should have been involuntarily detained overnight to allow medication overdose effects to clear and permit comprehensive discharge planning, though three experienced psychiat…

psychiatryemergency medicinediagnosticcommunicationpregabalin
WAhome2004-06-04

Inquest into the Death of Paul John Long

37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion

Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenti…

psychiatrygeneral practicecommunicationsystemquetiapine
VIChome2014-02-13

Finding into death of Daniel Malcolm John Anderson

33y · Male·toxic effects of oxycodone

…r the same indication due to addiction and adverse effect risks. The prescriber did not recognize opioid dependence development or exercise appropriate caution regarding long-term daily opioid use for a condition for whi…

general practicepsychiatrydiagnosticmedicationoxycodone
TAShospital2020-06-30

Coroner's Finding: Shrimpton, Dallas Brooks

54y · Male·carbon monoxide asphyxia

Dallas Brooks Shrimpton, a 54-year-old man with severe alcohol dependence, chronic depression, and multiple previous suicide attempts, died by carbon monoxide asphyxiation. He pr…

psychiatryemergency medicinecommunicationsystemalcohol
VIChome2017-08-16

Finding into death of CPLH

32y · Male·Multidrug overdose

A 32-year-old man with a history of polysubstance abuse, schizoaffective disorder, and chronic pain died from multidrug overdose at home. He had obtained fentanyl, clonazepam, diazepam, methadone, and other drugs from mu…

general practiceemergency medicinesystemcommunicationfentanyl
VIChospital2012-09-11

Finding into death of Robert Anderson

50y · Male·Complications of right buttock necrotising fasciitis secondary to chronic right …

…ole's practice of prescribing high-dose IM morphine for home self-injection to a patient with prior drug dependence fell far below accepted standards. No medical expert supported this approach. Proper chronic pain manage…

general practicepsychiatrydiagnosticmedicationmorphine sulphate
134511

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