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QLDhome2014-11-26

Wallrock, William Charles - Non-inquest findings

22y · Male·mixed drug toxicity due to methadone, codeine, and morphine (metabolite), compou…

William Wallrock, 22, died from mixed drug toxicity four days after wisdom tooth extraction. He was initially appropriately advised to use paracetamol and ibuprofen. When inadequate pain relief prompted him to seek furth…

dentistrygeneral practicemedicationcommunicationmethadone
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

…ined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered with antidep…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health A…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
VIChome2008-06-04

Finding into death of Kath Bergamin

37y · Female·unlawful killing

Kath Bergamin, a 37-year-old woman, disappeared from her home in Wangaratta, Victoria on 18 August 2002. She had recently left her husband John following years of psychological and physical abuse, obtaining intervention …

psychiatrygeneral practicesystemcommunicationcitalopram
VIChospital2022-05-04

Finding into death of Marlene Sako

25y · Female·self-immolation

…sment was conducted by a psychiatric nurse rather than a psychiatrist, did not adequately explore recent depression, and discharged her without verified safe discharge arrangements. She was found to be lacking mental ill…

emergency medicinepsychiatrydiagnosticcommunicationalcohol
VIChome2021-08-26

Finding into death of Mrs A

61y · Female·Ligature neck compression in the setting of blunt force head trauma

…ocumented family violence risk factors including prior threats, controlling behaviour, unemployment, and depression. He was receiving mental health treatment but did not disclose violent behaviour to his psychologist. Th…

general practicepsychologycommunicationsystem
VIC2010-01-11

Finding into death of Glenn Leslie Stevenson

45y · Male·Multiple injuries and fall from a height

Glenn Stevenson, 45, died by suicide by jumping from the Westgate Bridge on 6 April 2008. He had been admitted to Sunshine Psychiatric Hospital the previous day after presenting to the Royal Melbourne Hospital ED intoxic…

psychiatryemergency medicinesystemalcohol
TAShome2018-11-16

Coroner's Finding: Taylor, Michael John

50y · Male·methadone and alprazolam intoxication

Michael John Taylor, aged 50, died from methadone and alprazolam intoxication on 13 May 2016. He had chronic back pain and had been prescribed methadone and oxazepam since 2005. Evidence suggests he was crushing and inje…

general practicepain medicinecommunicationsystemmethadone
WAcommunity2020-10-22

Inquest into the Death of Jordana KOSTOVSKI

27y · Female·Multiple injuries sustained in motor vehicle collision

A 27-year-old woman under the influence of alcohol and methylamphetamine deliberately drove her van head-on into oncoming traffic on Forrest Highway, resulting in her death. Police had attempted to intercept her for dang…

forensic medicinetoxicologyalcohol
VIChome2015-10-28

Finding into death of Hannah Rachel Charles

17y · Female·Combined drug toxicity (heroin, codeine, methadone, benzodiazepines)

Hannah Charles, a 17-year-old with substance abuse issues, died from combined drug toxicity (heroin, codeine, methadone, benzodiazepines) at a private residence where she had been staying with two opioid replacement ther…

addiction medicineforensic medicinediagnosticsystemheroin
VIChome2017-04-19

Finding into death of Lauren Pilkington

20y · Female·Asphyxia secondary to inhalation of helium

Lauren Pilkington, a 20-year-old postgraduate student, died by asphyxia from helium inhalation. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission …

psychiatrygeneral practicesystemdelayfluoxetine
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…

Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 Decemb…

psychiatrypsychologycommunicationsystemzolpidem
VIChome2015-07-20

Finding into death of Brenton James Grosser

49y · Male·Drug toxicity (methadone)

Brenton Grosser, a 49-year-old man with alcohol addiction history, died from methadone toxicity after consuming three 100ml takeaway methadone bottles prescribed to his housemate. He had consumed significant alcohol (app…

toxicologyforensic medicinesystemmethadone
VICmental health2022-12-15

Finding into death of Christopher Traill

55y · Male·Hanging

Christopher Traill, a 55-year-old lawyer with alcohol dependence and depression, died by hanging in a psychiatric inpatient unit on 25 February 2017, just hours after admission as a co…

psychiatryproceduralcommunicationdiazepam
NSWhome2026-03-04

Inquest into the death of BX

29y · Male·Gunshot wound to the head, self-inflicted

… negotiation attempts, meaningful dialogue was not established. BX's untreated mental health conditions (depression, ADHD), history of substance use, and evasion of police were contributing factors. The coroner recommend…

communicationsystem
NSWcommunity2020-06-10

Inquest into the death of Christopher McGRAIL

44y · Male·Gunshot wounds to the trunk and right thigh with subsequent blood loss

Christopher McGrail, a 44-year-old man with a history of substance abuse, depression, and trauma following his son's suicide, was shot by NSW Police during a knife confrontation. He present…

emergency medicinepsychiatrymethamphetamine
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

… seized the firearm from Correctional Services Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predica…

psychiatrycorrectional healthsystemcommunicationmethadone
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide on 2 October 2007 a…

psychiatrygeneral practicecommunicationsystemstillnox
VICprison2024-12-11

Finding into death of Jayke Michael Aleckson

24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging

…2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medication despite documented depression history and clear clinical indication—a significant departure from reasonable care standards; (2) Failur…

psychiatrygeneral practicediagnosticcommunicationfluoxetine
TAScommunity2022-12-15

Coroner's Finding: Wildman, Benjamen

37y · Male·self-inflicted stab wound to the chest

Benjamen Robert Wildman, aged 37, died from a self-inflicted stab wound to the chest while in police custody on 29 December 2020. He had a lifelong history of mental health difficulties, personality dysfunction stemming …

psychiatrypsychology
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