Coronial

181 results for poor medication compliance

TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

…smania. He had a long history of psychosis and depression dating from age 14, treated with antipsychotic medication with variable compliance. In the weeks before death, he experienced escalating paranoia and delusional i…

psychiatryemergency medicinedelaymethamphetamine
VIChospital2021-06-10

Finding into death of Carlene Margaret Salveson

80y · Female·pulmonary thromboembolism in the setting of deep leg vein thrombosis; squamous c…

…om pulmonary thromboembolism secondary to bilateral deep vein thrombosis. She was admitted to hospital with poor oral intake, dehydration, and acute kidney injury following chemotherapy and radiotherapy. Critical risk fa…

radiation oncologyoncologymedicationsystem
VICcommunityPodcast2024-03-15

Finding into death of Colleen Mary South

58y · Female·Unascertained

…tive disorder, bipolar disorder, depression and anxiety, managed with antipsychotic and mood-stabilising medications, though she had poor medication compliance. She had previously wandered considerable distances during m…

psychiatryemergency medicinesystemdelayaripiprazole
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

… DJ died in 2012 from injuries inflicted by cellmate BB, who was treatment-resistant, non-compliant with medication, and acutely psychotic. Both deaths were preventable through better mental health screening, risk assess…

psychiatrydiagnosticcommunicationquetiapine
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

… in December 1994 and discharged January 1995 with documented suicidal ideation. He subsequently stopped medication against medical advice, deteriorated significantly with paranoid delusions and self-neglect, yet psychia…

psychiatrypsychologysystemcommunicationantipsychotic medication
SAcommunity2011-12-22

Coroner's Finding: HYNES Simon Christopher

41y · Male·acute neck compression due to hanging

…ng detention order. He had a 20-year history of schizoaffective disorder requiring ongoing antipsychotic medication and community treatment orders. Despite being subject to a community treatment order requiring fortnight…

psychiatryforensic medicinedelaycommunication
WAcommunity2023-02-03

Inquest into the Suspected Death of Roly NIXON

44y · Male·Unascertained; presumed exposure

…g, Western Australia on 28 January 2018. He had been drinking alcohol and was not carrying his essential medications (warfarin and levetiracetam). Medical staff had advised he was at high risk of seizures and stroke with…

emergency medicinecardiologywarfarin
VIChome2025-09-02

Finding into death of Mr IKL

29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…

…ting doses of opioids, benzodiazepines, and other drugs of dependence without therapeutic justification. Medications were prescribed to facilitate sexual acts, in response to non-clinical requests via personal messages, …

general practicepsychiatrydiagnosticmedicationgabapentin
VIChome2016-11-11

Finding into death of John Raynox Jansen

51y · Male·Blunt head injury sustained in the circumstances of a seizure

John Jansen, a 51-year-old man with poorly controlled epilepsy and chronic alcoholism, died from blunt head injury sustained during a seizure in his…

neurologygeneral practicemedicationsodium valproate
VICcommunity2015-03-03

Finding into death of Jahit Elliott Alieff

27y · Male·hanging

… hospitalization in December 2008 and managed by an outpatient team. The coroner found his care hindered by poor engagement and reduced monitoring. Although Mr Alieff received his depot medication regularly and showed no…

psychiatrycommunicationsystemrisperidone
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

…and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with antisocial personality traits, poor medication compliance, amphetamine abuse, and morbid jealousy directed at Ms Dinsdale. Despite intensive me…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIChome2014-03-06

Finding into death of Melanie Jane Maher

36y · Female·Effects of fire (schizophrenic psychotic episode); for children: effects of fire…

…rimary care—must be systematically addressed. The case illustrates how disconnection from medical services, poor medication compliance, and lack of safety planning can lead to catastrophic outcomes.

psychiatrygeneral practicecommunicationsystemrisperidone
NSW2024-02-01

Inquest into the death of Timothy Garner

31y · Male·Hanging

…July 2018 given his limited engagement with assessors, active psychosis, repeated self-harm attempts and medication non-compliance. He was not reviewed between 2-7 July despite the psychiatrist's plan for follow-up withi…

psychiatrycorrectional healthdiagnosticcommunicationquetiapine
WA2025-05-05

Inquest into the Suspected Death of David Benjamin INGRAM

44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…

…relevant to safety, (3) recognising decompensation in patients with psychotic illness, particularly when medication compliance is uncertain, and (4) ensuring crew awareness of mental health support resources and escalati…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChomePodcast2018-11-09

Finding into death of Le Hue Huynh

46y · Female·hypoxic ischaemic encephalopathy complicating cardiorespiratory arrest in the se…

…atory arrest during the November 21, 2016 Thunderstorm Asthma event in Melbourne. She had known asthma with poor medication compliance, was highly sensitized to rye grass pollen, and had hay fever. She called 000 at 6:42…

emergency medicineintensive caresystemdelaysalbutamol
NSWaged care2014-05-23

Inquest into the death of Beryl Joyce WATSON

70y · Female·Aspiration pneumonia, associated with Huntington's disease

… respite stay at a BUPA aged care facility. Critical failures included: omission of essential clonazepam medication from dispensing lists due to GP record-keeping errors, inadequate recognition of benzodiazepine withdraw…

geriatric medicinegeneral practicemedicationcommunicationclonazepam
VICmental health2013-08-20

Finding into death of Hassan Yassin

35y · Male·Hanging

…linicians' failure to use least restrictive environment principles while maintaining involuntary detention, poor inter-service communication, and absence of clear follow-up protocols directly contributed to a preventable…

psychiatryemergency medicinecommunicationsystemrisperidone
NT2012-07-13

Inquest into the death of Edward Brown

34y · Male·coronary atherosclerosis (heart attack)

…ry atherosclerosis while in custody. He had type 2 diabetes diagnosed in 2007 but was non-compliant with medications and lifestyle modifications. Upon reception to prison, he was appropriately screened, found to have ele…

cardiologyemergency medicinemetformin
SAhome2022-12-16

Coroner's Finding: Reid, Paul

50y · Male·ischaemic heart disease

Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was hi…

cardiologyforensic medicinediagnosticsystemalcohol
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

…rrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical comorbidities (cardiac disease, COPD, obesity). The coroner found preven…

psychiatrygeneral practicediagnosticmedicationolanzapine
134510

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