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WAmental health2021-06-29

Inquest into the Death of Samuel Mark WALSH

38y · Male·carbon monoxide toxicity

Samuel Mark Walsh died by carbon monoxide toxicity (suicide) in October 2014 while subject to a custody order for a forensic mental health condition. He had paranoid schizophrenia and had been remarkably stable on clozap…

psychiatrypharmacydelaysystemclozapine
VIChome2021-06-29

Finding into death of HM

15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…

HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension. He had dysfunctional eating patterns, …

paediatricspsychiatrysystemdelaylovan
SAprison2021-06-28

Coroner's Finding: STACHOR Joshua Marek

30y · Male·Hanging

Joshua Stachor, aged 30, died by hanging in Yatala Labour Prison on 19 November 2017. He was a remand prisoner on charges of domestic violence. The coroner found critical failures in his admission assessment on 6 Novembe…

correctional healthgeneral practicediagnosticcommunicationprochlorperazine
VICcommunity2021-06-28

Finding into death of Hassan Khalif Shire Ali

74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest; Hassan Khalif Shire Ali: gunshot wo…

A 74-year-old Italian-Australian, Sisto Malaspina, was fatally stabbed during a terrorist attack in Melbourne's CBD on 9 November 2018. Hassan Khalif Shire Ali, aged 30, detonated an improvised explosive device in his ve…

psychiatryemergency medicinesystemcommunicationcannabis
VICcommunity2021-06-28

Finding into death of Sestilio Malaspina

74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…

On 9 November 2018, Hassan Khalif Shire Ali committed a premeditated ISIS-inspired terrorist attack in Bourke Street, Melbourne, using an improvised explosive device in his vehicle followed by a knife assault. He fatally…

psychiatryemergency medicinesystemcommunicationcannabis
VICaged care2021-06-23

Finding into death of Kathryn O'Rourke

48y · Female·Hypoxic/Ischaemic Encephalopathy; Aspiration of Food with Respiratory Arrest wit…

Kathryn O'Rourke, aged 48, a resident with severe intellectual disability and dysphagia in a disability residential care facility, aspirated a piece of toast during breakfast on 10 May 2018 and died from hypoxic-ischaemi…

intensive careemergency medicinecommunicationsystemclonazepam
NSWhome2021-06-18

Inquest into the death of Julian HORNE

47y · Male·acute alcohol intoxication

Julian Horne, 47, died from acute alcohol intoxication at home after 11 hospital admissions in 6 weeks during a severe binge relapse. He had lifelong struggles with alcohol, depression and anxiety, previously tried multi…

emergency medicineaddiction medicinesystemcommunicationalcohol
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

Teresa Bradford, aged 40, was killed by her husband David Bradford in a premeditated domestic homicide at their Pimpama home on 31 January 2017, followed by his suicide. She died from head injuries inflicted with an axe.…

general practicepsychiatrycommunicationsystemwarfarin
NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…

psychiatrycorrectional healthcommunicationsystemolanzapine
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
NSWcommunity2021-06-08

Inquest into the death of Zhong Liu

54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…

54-year-old man with schizophrenia died after acute mental health crisis during police response. Contributing factors included: arrhythmogenic cardiomyopathy (undetected cardiac condition); combined doxepin and venlafaxi…

psychiatrygeneral practicemedicationcommunicationdoxepin
VIChospital2021-05-31

Finding into death of Ms Jane

13y · Female·hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate toxicity

Jane, aged 13, died from hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate (GHB) toxicity following accidental overdose. She ingested an estimated 6-9mls of GHB in early June 2017, having used the drug …

emergency medicineintensive caregamma hydroxybutyrate
SAhome2021-05-28

Coroner's Finding: LOCKWOOD Andrew James

49y · Male·Shotgun wound to the head

Andrew Lockwood, a 49-year-old man with depression and significant marital discord, died from a self-inflicted shotgun wound to the head on 2 April 2017. He had been diagnosed with major depression and alcohol dependency…

general practicepsychiatrysertraline
QLD2021-05-28

Scorsese, Liam Cooper

31y · Male·Gunshot wounds to the neck and chest

Liam Scorsese, 31, died from gunshot wounds inflicted by police during a confrontation at his estranged partner's parents' home in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideation a…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NSWhospital2021-05-27

Inquest into the death of George McLEOD

80y · Male·Atherosclerotic cardiovascular disease, with dementia, diabetes mellitus and hyp…

An 80-year-old man with extensive medical comorbidities (atherosclerotic cardiovascular disease, dementia, diabetes, hypertension, COAD, previous MI with bypass grafts) died in custody at Long Bay Hospital from natural c…

forensic medicinegeriatric medicine
QLD2021-05-24

SVE

43y · Male·Hanging

A 43-year-old man remanded in custody for serious sexual offences against children died by hanging in an older prison cell. While he expressed fears about safety and had passive suicidal ideation months before his death,…

psychiatrypsychologysystemdelay
VIC2021-05-24

Finding into death of Melanie Diane Doherty

29y · Female·Mixed Drug Toxicity

A 29-year-old woman died from mixed drug toxicity after being found unresponsive at a residential parenting program. She had complex medical conditions including coproporphyria, epilepsy, and opioid use disorder. Critica…

addiction medicinepsychiatrymedicationcommunicationmethadone
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…

general practicepsychiatrydiagnosticdelaylithium
TASmental health2021-05-21

Coroner's Finding: Hanson, Sungwaan

64y · Female·stage IVB metastatic adenocarcinoma of the rectum

Sungwaan Hanson, a 64-year-old woman with a 35-year history of treatment-resistant schizophrenia, died from stage IVB metastatic adenocarcinoma of the rectum at the Roy Fagan Centre on 27 May 2020. She had been subject t…

psychiatrygeneral medicine

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