Coronial

84 results for possible alcohol use disorder

VIChome2008-06-04

Finding into death of Kath Bergamin

37y · Female·unlawful killing

…a on 18 August 2002. She had recently left her husband John following years of psychological and physical abuse, obtaining intervention orders. At the time of disappearance, she was rebuilding her life—working, studying…

psychiatrygeneral practicesystemcommunicationcitalopram
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode.…

psychiatryemergency medicinediagnosticsystemcannabis
QLDmental health2005-11-09

Community Mental Health Patient

20y · Male·hanging

A 20-year-old male with major depressive disorder and melancholic features was admitted to psychiatric hospital on 4 June 2003 under an indefinite involunt…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICcommunity2013-05-08

Finding into death of Marella Johnson

32y · Female·Bilateral haemothoraces with multiple rib fractures and fracture dislocation of …

Marella Johnson, a 32-year-old Aboriginal woman with schizophrenia and schizoaffective disorder, was involuntarily admitted to Alexander Bayne Centre on 17 February 2008 after presenting to Echuca Regi…

psychiatryemergency medicinesystemdelayzuclopenthixol
VIChospital2022-05-04

Finding into death of Marlene Sako

25y · Female·self-immolation

Marlene Sako, a 25-year-old woman struggling with alcohol dependence following a traumatic marriage breakdown, presented to Northern Hospital on 29 November 2015 w…

emergency medicinepsychiatrydiagnosticcommunicationalcohol
TAS2015-08-01

Coroner's Finding: Leemhuis, Leah Maree

46y · Female·Multiple severe trauma suffered in a motor vehicle accident

…sleep. Investigation revealed she was taking diazepam (therapeutic level), sertraline (high level), and had used cannabis. The forensic pathologist noted this drug combination likely contributed to drowsiness. The coron…

psychiatrygeneral practicecommunicationdiazepam
WAcommunity2026-02-02

Inquest into the Death of Joshua Fredrik VAN MALSSEN

24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…

… being restrained in prone position by PTA transit officers at Perth Underground Train Station. Following disorderly conduct and alcohol intoxication, officers used a harness takedown and handcuffs to detain him. While r…

communicationproceduralalcohol
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…h autism and intellectual disability. The coroner found he intended to take his own life, and in doing so caused his son's death. Conan had treated depression and anxiety with mirtazapine, reported as effective at his l…

psychiatrygeneral practicecommunicationdelaymirtazapine
VICcommunity2024-08-07

Finding into death of Jason

50y · Male·Neck compression secondary to hanging

…personal safety alarm response in family violence contexts. Jason had prior suicide attempts, depression, alcohol use disorders, history of perpetrating violence, and recent relationship separation. Clinicians should un…

general practicepsychiatrysystemcommunicationvenlafaxine
TAShospital2021-02-05

Coroner's Finding: Lattimer, Joseph Aaron

37y · Male·hypoxic encephalopathy due to asphyxia from hanging

Joseph Aaron Lattimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring ass…

emergency medicinepsychiatrysystemdelayalcohol
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with …

psychiatryintensive carecommunicationsystempaliperidone
NSW2020-02-13

Inquest into the death of LP

34y · Male·Foreign body aspiration

…iolent crime. He fashioned an airway obstruction from toilet paper and meal pack plastic packaging whilst housed in an assessment cell under CCTV monitoring and suicide risk protocols. The case identifies policy gaps in…

psychiatrycorrectional healthsystemcommunication
VICmental health

Finding into death of GM

52y · Male·Unascertained

GM, a 52-year-old man with bipolar affective disorder, died of unascertained causes after absconding from a mental health inpatient unit on 2 December 2015. He…

psychiatryemergency medicinesystemcommunicationpholcodine
VICmental health2012-03-13

Finding into death of Matthew Spalding

28y · Male·neck compression subsequent upon hanging

Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute …

psychiatryemergency medicinecommunicationsystemaripiprazole
TAS2026-06-03

Coroner's Finding: Brown, Nicholas, Wiki, Toni, Winwood, Matthew and Kemp, Belinda

Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …

…and reviews, absent urine drug screening, and poor record-keeping. Dr J.'s negligent prescribing directly caused deaths of Brown and Winwood from combined drug toxicity. Kemp died of pneumonia with prescription drug tox…

addiction medicinegeneral practicediagnosticmedicationmethadone
ACTcommunity2025-08-12

Inquest into the death of Stanley McIntyre

63y · Male·pulmonary emphysema

Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Treatment Order. He had advanced COAD diagnosed only one mon…

psychiatrygeneral practicehaloperidol
VIC2022-07-28

Finding into death of Master S

17y · Male·Unascertained in the setting of volatile substance abuse

Master S, a 17-year-old Yorta Yorta young man, died on 3 July 2017 at the Bert Williams Hostel from a cause unascertained in the setting of volatile substance abuse (chroming Rexona deodorant). He had a history of e…

paediatricspsychiatrycommunicationsystemrexona deodorant
NSWcommunity2023-11-17

Inquest into the death of SB

51y · Male·Stab wounds to the chest

A 51-year-old man with documented mental health issues including psychosis, paranoia, and delusions died from self-inflicted stab wounds during a police siege at his mother's home. He had breached a domestic violence ord…

psychiatryemergency medicinecommunicationsystemolanzapine
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…

correctional healthgeneral practicediagnosticcommunicationmethadone
WA2025-03-10

Inquest into the Death of Ricky-Lee COUND

22y · Male·ligature compression of the neck (hanging)

Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…

psychologygeneral medicinediagnosticcommunicationaripiprazole

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