Coronial

113 results for substance misuse

VICcommunity2011-03-30

Finding into death of Geoffery Reginald Bragge

26y · Male·amylobarbital overdose

Geoffrey Reginald Bragge, aged 26 at presumed death, disappeared on 31 August 1971 following discharge from St Vincent's Hospital psychiatric unit after treatment for a drug overdose. Unidentified remains found in the Ya…

psychiatryemergency medicinecommunicationsystemamylobarbital
VIChome2017-02-22

Finding into death of KD

56y · Male·Aspiration of gastric content secondary to combined drug toxicity

…r high-risk patients with addiction histories, and monitoring non-scheduled drugs like quetiapine that are misused in addiction populations.

general practicepsychiatrycommunicationsystemdiazepam
VIChome2017-07-04

Finding into death of NJ

35y · Female·combined drug toxicity

A 35-year-old woman with long-standing substance use disorder, depression, and chronic pain died from combined drug toxicity involving methadone, pregaba…

general practiceaddiction medicineprescribingcommunicationmethadone
VIC2014-05-01

Finding into death of Denis Stephen Kelly

62y · Male·Head, neck and chest injuries

…lence, with research indicating increased risk of assault related to depression, mental health problems, substance misuse, and lack of safe shelter. This case underscores the public health importance of addressing homel…

SAhospital2013-04-24

Coroner's Finding: HOLLONDS Andrew David

37y · Male·compression of the neck consistent with hanging

Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) followi…

psychiatryemergency medicinesystemcommunicationtemazepam
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

…cribed high-dose tramadol (700-800mg daily) for chronic pain over 22 months by his GP without documented substance abuse assessment, despite documented history of polysubstance dependence. When Eckersley ceased alcohol …

general practicepain medicinemedicationcommunicationtramadol
VICcommunity2013-12-20

Finding into death of Jade Lesley Dorogi

25y · Male·Cerebral hypoxia and multisystem organ failure from heroin (morphine) toxicity

Jade Dorogi, a 25-year-old man with a history of drug addiction but no prior heroin use, died from cerebral hypoxia and multisystem organ failure following heroin toxicity. He ingested heroin on 4 May 2009 with his cousi…

forensic medicineemergency medicinedelayheroin
ACThome2019-09-20

Inquest into death of Kurt Mellick Andriske

52y · Male·septicaemia caused by Streptococcus Milleri group pneumonia

…actor. He was a complex patient with bipolar disorder, chronic pain, hepatitis B and C, and a history of substance use managed by a single GP. Dr W. co-prescribed benzodiazepines (Diazepam and Oxazepam) for anxiety and …

general practicepsychiatrydiazepam
QLDhome2010-06-09

Edwards, Peeta Louise Josephine

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

Mrs Edwards, a 32-year-old woman with severe depression and psychiatric history, was found dead in bed. Autopsy revealed opiate toxicity with high levels of morphine and codeine. Toxicology expert opinion indicated morph…

general practicepsychiatrysystemdelaymorphine
TAScommunityNew2026-05-19

Coroner's Finding: de-identified FI

51y · Female·multiple (head, chest, pelvic and limb) injuries

…t, Tasmania, on 9 October 2023. A 51-year-old female driver with a history of bipolar disorder and alcohol misuse entered the north-bound lanes of a divided highway when she should have entered the south-bound lanes. She…

alcohol
TAShospital2022-02-08

Coroner's Finding: Bruinewoud, Brieley Joyce

36y · Female·Traumatic closed head injury

A 36-year-old theatre nurse died from traumatic closed head injury after jumping from a moving vehicle whilst heavily intoxicated. She had consumed most of a bottle of vodka over 12 hours at a party and had a blood alcoh…

neurosurgerytrauma surgeryalcohol
VIC2014-09-11

Finding into death of Lloyd Felman

58y · Male·Amitriptyline toxicity

…iculty: Mr Felman presented with established risk factors (chronic pain, depression, prior attempt 2005, substance use) yet consistently denied current suicidal intent and provided alternative explanations for behaviour…

psychiatryemergency medicineamitriptyline
VICcommunity2020-05-07

Finding into death of Mark Beames

44y · Male·Unascertained

…for vulnerable patients with complex needs, ensuring medication compliance in patients with epilepsy and substance use disorders, and coordinated care across mental health, addiction services and primary care for patien…

psychiatryneurologydiazepam
QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

…e seizure of potential evidence. The case highlights the catastrophic consequences of unmanaged parental substance abuse on child safety and the need for better systems to identify and intervene in prescription opioid m…

paediatricsgeneral practicemedicationdiagnosticmorphine
SAcommunity, workplace2019-10-23

Coroner's Finding: Murray, Erin Paige and Patterson, Amy Jean

Female·pentobarbitone toxicity

…th women had access to lethal pentobarbitone through veterinary workplaces despite it being a Schedule 4 substance requiring only public exclusion. Key clinical lessons: pentobarbitone, a highly concentrated and rapidly…

veterinary medicinepsychiatrysystemdelaypentobarbitone
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…

Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…

general practicepain medicinediagnosticmedicationfentanyl
ACThospital2016-12-16

AN INQUEST INTO THE DEATH OF PAUL FENNESSY

21y · Male·combined effect of a cocktail of drugs causing central nervous system depression…

Paul Fennessy, a 21-year-old with polysubstance addiction and mental health issues, died from positional asphyxia following a drug overdose on 6 January…

emergency medicinepsychiatrycommunicationsystemmethadone
SAhospital2018-07-19

Coroner's Finding: ROSS Chrystal Jessica

24y · Female·hypoxic brain injury secondary to hanging

…es and care coordination errors. She had been admitted to Mount Barker Hospital for anxiety, depression, substance misuse concerns, and self-harm behaviours. After one week, a psychiatrist recommended admission to a spe…

psychiatrygeneral practicecommunicationdiagnosticfluvoxamine
VIChospital2025-06-25

Finding into death of RFV

87y · Male·Consequences of an assault with severe facial fractures

RFV, an 87-year-old man, died from severe facial fractures and traumatic brain injury sustained during an assault by his daughter-in-law. He presented to hospital in critical condition with cardiac arrest, multiple facia…

emergency medicineintensive caresystem
TAShome2022-08-03

Coroner's Finding: Linklater, Brian Gary

50y · Male·mixed drug and alcohol toxicity (pentobarbitone and ethanol)

Brian Gary Linklater, aged 50, died from mixed drug and alcohol toxicity after intentionally injecting pentobarbitone (a barbiturate used in veterinary practice) obtained from his partner's vehicle and consuming vodka. H…

pentobarbitone

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