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SAhospital2020-12-18

Coroner's Finding: ASTACHNOWICZ Maria

76y · Female·left lower lobe pneumonia complicating metapneumovirus infection

Maria Astachnowicz, aged 76, died from left lower lobe pneumonia complicating metapneumovirus infection at Lyell McEwin Hospital. She had extensive psychiatric history (schizoaffective disorder/bipolar) with chronic ment…

psychiatrygeriatric medicineclonazepam
QLDprison2020-12-17

Hobbs, Richard William

48y · Male·Coronary atherosclerosis with acute cardiac event

Richard William Hobbs, aged 48, died from cardiac arrest in custody at Brisbane Correctional Centre on 21 November 2017. He had significant comorbidities including coronary artery disease (recent stent insertion), diabet…

emergency medicinecardiologydiagnosticcommunicationaspirin
QLDhospital2020-12-17

Aitkenhead, Alexander David

86y · Male·Ischaemic heart disease on a background of valvular heart disease, prostatic enl…

An 86-year-old prisoner with multiple chronic illnesses (COPD, atrial fibrillation, emphysema) died of ischaemic heart disease in a palliative care unit. He was admitted to hospital on 21 April 2019 with end-stage COPD a…

palliative caregeriatric medicinewarfarin
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …

paediatricspsychiatrydiagnosticcommunicationalcohol
ACTcommunity2020-12-14

Inquest into the death of DANIEL JAMES CLEMENT

30y · Male·unascertained

Daniel James Clement, a 30-year-old man with schizophrenia on a Psychiatric Treatment Order, disappeared from his mother's home in late May 2017 and was found deceased on the Murrumbidgee River in November 2017. His caus…

psychiatrygeneral practicesystemcommunicationzuclopenthixol
NSW2020-12-11

Inquest into the death of SB -findings - 11 December 2020

38y · Male·asphyxiation by ligature

A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…

psychiatrypsychologycommunicationsystemmirtazapine
VICcommunity2020-12-09

Finding into death of Maggie Rose Bant

20y · Female·Plastic bag asphyxia with inhalation of helium

A 20-year-old woman with a history of depression, anxiety, and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disc…

general practicepsychiatrydiagnosticcommunicationsertraline
VIC2020-12-09

Finding into death of Alma Lynette Honeychurch

76y · Female·Ludwig's angina

A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…

emergency medicinedentistrydiagnosticcommunicationantibiotics
VIChome2020-12-01

Finding into death of Mitchell Boyd Branson

20y · Male·Hanging

Mitchell Boyd Branson, aged 20, died by hanging in Mildura in June 2019. He had a documented history of mental illness including PTSD stemming from exposure to traumatic internet imagery at age 10, a prior suicide attemp…

psychiatrygeneral practicecommunicationdelayalcohol
VICcommunity2020-11-27

Finding into death of Nicholas Daniel Ficarra

26y · Male·unascertained; suspected suicide by firearm

Nicholas Daniel Ficarra, aged 26, disappeared on 14 January 2012 from his family farm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 200…

psychiatrygeneral practicesystemdelayheroin
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
TAScommunity2020-11-23

Coroner's Finding: Golding, Laura Rebecca

51y · Female·drowning

Laura Golding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay withou…

psychiatrygeneral practicesystemdelay
VIChome2020-11-20

Finding into death of Baby S

1y · Male·head injury

Baby S, a 12-month-old boy, died from head injuries inflicted by his mother's de facto partner, Mr B, while the mother was away obtaining heroin. The child had multiple previous injuries documented by childcare staff and…

paediatricsgeneral practicediagnosticcommunicationheroin
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…

general practiceforensic medicinecommunicationsystemoxycodone
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents as both perpetrator and victim in relationships, leading to…

psychiatrygeneral practicecommunicationsystemvenlafaxine
TAShome2020-11-09

Coroner's Finding: Spencer, Melissa Mary

54y · Female·mixed drug toxicity

A 54-year-old nurse with chronic pain from a 1990 back injury died from mixed drug toxicity involving morphine, codeine, doxylamine and nitrazepam. She was prescribed multiple CNS depressants for years despite being desi…

general practicepain medicinemedicationsystemmorphine
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…

psychiatrypsychologysystemcommunicationantidepressants
VIChome2020-11-06

Finding into death of Robert Thomas Love

33y · Male·Undetermined

Robert Thomas Love, a 33-year-old man with a history of alcohol and drug abuse and mental health difficulties, was found dead in his home in February 2015. The cause of death remains undetermined. Key clinical concerns i…

addiction medicinegeneral practicebaclofen
WAcommunity2020-11-05

Inquest into the Suspected Death of Paul Clifford YORK

45y · Male·unascertained

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…

psychiatrygeneral practicediagnosticsystemmirtazapine
VICaged care2020-11-05

Finding into death of Sylvia Valerie Woolford

88y · Female·Complications of fractured neck of femur

An 88-year-old woman with advanced dementia died from complications following a fractured neck of femur sustained in a fall caused by another resident with vascular dementia in a secured aged care unit. The fall occurred…

geriatric medicineorthopaedic surgerysystem

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