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VIChospital2021-08-16

Finding into death of David John Main

54y · Male·Toxic leukoencephalopathy (of uncertain aetiology)

David Main, 54, died from toxic leukoencephalopathy of uncertain aetiology following a ketamine-assisted oxycodone detoxification at Beleura Private Hospital. He had chronic pain from multiple injuries and opioid depende…

pain medicineanaesthesiaketamine
VIChome2021-08-12

Finding into death of M J

37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…

MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…

general practicepsychiatrysystemcommunicationmethamphetamine
VICaged care2021-08-12

Finding into death of Valerie Lucy Jones

86y · Female·Plastic bag asphyxia

An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, an…

general medicinegeriatric medicinecommunicationsystemmirtazapine
WAhome2021-08-10

Inquest into the Death of Scott William MARTIN

40y · Male·Penetrating wounds to the chest

Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
TAS2021-08-04

Coroner's Finding: Bester, Alec Laurence

78y · Male·Aspiration pneumonia complicating advanced multifactorial dementia

Alec Bester, a 78-year-old man with advanced dementia (primarily alcohol-related), chronic alcoholism, emphysema, and ischaemic heart disease, died of aspiration pneumonia at the Roy Fagan Centre. He vomited after his ev…

geriatric medicinepsychiatry
VIChome2021-08-03

Finding into death of V T

75y · Female·Multiple injuries including stab wounds to the chest

A 75-year-old woman was fatally stabbed by her son during a family violence incident. Her son had a 20-year history of schizophrenia and schizoaffective disorder with poor medication compliance, documented aggression tow…

psychiatrygeneral practicecommunicationsystem
VIChome2021-08-02

Finding into death of Mark Marian Milewski

71y · Male·Mixed drug toxicity

A 71-year-old man with multiple chronic conditions including obesity, diabetes, heart failure, and chronic pain died from mixed drug toxicity involving oxycodone, codeine, diazepam, and alcohol. The coroner determined he…

general practicegeriatric medicinediagnosticoxycodone
WAhospital2021-07-30

Inquest into the Death of Chad RILEY

39y · Male·Cardiac arrhythmia following violent exertion necessitating physical restraint i…

39-year-old Chad Riley died from cardiac arrhythmia following violent exertion during physical restraint. He presented to hospital intoxicated with methylamphetamine, exhibiting drug-induced psychosis with agitation and …

emergency medicinepsychiatrysystemmethamphetamine
VIChome2021-07-30

Finding into death of GAMcM

45y · Male·Hanging

A 45-year-old man with depression died by hanging after experiencing significant workplace stress. He had consulted his GP in October 2014 regarding grief over his mother's terminal illness and was prescribed sleeping ta…

general practicepsychologydelaysertraline
NSWcommunity2021-07-30

Inquest into the death of A J

36y · Male·multiple injuries consistent with a fall from a height

A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…

psychiatrycorrectional healthcommunicationdelaysertraline
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLD2021-07-26

Cunningham, Luke

21y · Male·Hanging

Luke Cunningham, aged 21, died by hanging in a prison cell at Arthur Gorrie Correctional Centre in Queensland in September 2018. He was on remand facing murder charges. An initial psychological assessment upon reception …

psychiatrycorrectional healthsystem
VICcommunity2021-07-26

Finding into death of Adam Laufer

32y · Male·Multiple injuries sustained in a fall from a height

Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called tr…

psychiatrypsychologysystemcommunication
VIChospital2021-07-20

Finding into death of Gela Anne Vigor-Newitt

72y · Female·Pneumonia as a consequence of chronic obstructive airway disease

Ms Vigor-Newitt, a 72-year-old woman in prison, died from pneumonia complicated by chronic obstructive airway disease. She had presented with respiratory symptoms on 27 and 29 September 2020 and was appropriately hospita…

respiratory medicinecardiologysalbutamol
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
VIChome2021-07-14

Finding into death of Edward Michael Espino

36y · Male·neck compression in the circumstances of hanging

Edward Espino, a 36-year-old man with bipolar affective disorder, died by hanging on 1 February 2016. In the hours preceding his death, he learned of a police 'whereabouts' alert placed six months after a minor assault a…

psychiatryforensic medicinesystemsodium valproate
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtain…

psychiatrypsychologysystemproceduralpentobarbitone
SAhospital2021-06-30

Coroner's Finding: VOIVODICH Guido

84y · Male·general inanition on a background of end-stage dementia and a fractured neck of …

84-year-old man with end-stage dementia died from general inanition following a fractured neck of femur sustained while under a Level 2 Inpatient Treatment Order. He was admitted in January 2019 with confusion and agitat…

psychiatrygeriatric medicineapixaban
SAhospital2021-06-30

Coroner's Finding: MOKETARINJA Anthea Ryder

42y · Female·multiple organ failure due to sepsis on a background of pneumonia, spontaneous b…

Anthea Ryder Moketarinja, a 42-year-old Aboriginal woman with advanced cirrhosis, died from multiple organ failure due to sepsis, pneumonia, spontaneous bacterial peritonitis, and end-stage liver disease. She was admitte…

general medicinepsychiatryantibiotics
SAhospital2021-06-30

Coroner's Finding: MAZMANIDIS Kiriakos Jack

83y · Male·respiratory failure due to chronic obstructive lung disease

An 83-year-old man with chronic obstructive pulmonary disease, suspected mesothelioma, and recurrent respiratory infections presented with type 2 respiratory failure and delirium secondary to hypoxia and lower respirator…

respiratory medicineintensive carehaloperidol

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