Coronial

101 results for CNS depression

VIChospital2023-03-10

Finding into death of Armin Andrew Schaefer

63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…

…sychiatric unit. He presented to ED on 15 August 2019 with acute psychosis requiring sedation with multiple CNS-depressing medications (diazepam, olanzapine, droperidol, promethazine, chlorpromazine). Critical failures …

psychiatryemergency medicinediagnosticcommunicationdiazepam
VIChome2017-06-20

Finding into death of Finding Ms RF

50y · Female·Potentially fatal multiple drug toxicity (oxycodone, mirtazapine, citalopram, cl…

Ms RF, a 50-year-old woman with epilepsy and chronic pain from a workplace wrist injury, died from potentially fatal multiple drug toxicity involving oxycodone, mirtazapine, citalopram, clonazepam, and pregabalin. She en…

general practiceneurosurgerysystemcommunicationoxycodone
VICcommunity2026-07-08

Finding into death of Linda Joy Bridle

72y · Female·Combined drug toxicity (tapentadol, fluoxetine)

Linda Joy Bridle, 72, died from combined drug toxicity (tapentadol and fluoxetine) with a contributing subdural haemorrhage. She had multiple chronic conditions including heart failure and chronic pain, managed through c…

general practicepharmacymedicationcommunicationtapentadol
TAScommunity2016-05-25

Coroner's Finding: Barnes, Deearne Joan

53y · Female·mixed prescription drug toxicity

Deearne Joan Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity …

psychiatrypain medicinediagnosticmedicationvenlafaxine
VICcommunity2016-11-22

Finding into death of Claire Marguerite Martin

28y · Female·methadone toxicity

…g) would have been more appropriate. She received concurrent benzodiazepines and antipsychotics, increasing CNS depression risk. Daily supervised dosing occurred at the pharmacy with clinical checks, but no concerns wer…

addiction medicinepsychiatrydiagnosticmedicationmethadone
TAS2015-08-01

Coroner's Finding: Leemhuis, Leah Maree

46y · Female·Multiple severe trauma suffered in a motor vehicle accident

A 46-year-old woman died in a head-on motor vehicle collision after her car drifted across the centre line on the Bass Highway. She had reported feeling tired earlier that morning and had intended to pull over to sleep. …

psychiatrygeneral practicecommunicationdiazepam
VICcommunity2019-06-18

Finding into death of Yara Sturak Mignon

35y · Male·Hypoxic brain injury complicating cardiac arrest in the setting of combined hero…

…d in November 2018. He had combined heroin, alcohol, and doxylamine (antihistamine), causing respiratory depression and cardiac arrest. Despite 22 minutes of paramedic CPR and hospital admission, he suffered irreversible…

emergency medicineintensive caresystemheroin
WAhome2018-08-03

Inquest into the Death of Jackie-Lee SMITH

56y · Female·Acute combined drug toxicity

…n side effects may lead to dose escalation; and considering the risks of fall-related deaths in patients on CNS-depressant medications. No evidence supports involvement of a third party or intentional overdose.

general practicepain medicinetramadol
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, …

psychiatrygeneral practicecommunicationsystemtapentadol
NSWcommunity2026-02-24

Inquest into the deaths of Jebriel Dandan and Seiffedine Malas

24y · Male·Multiple Traumatic Injuries sustained as a result of motor vehicle crash during …

…driver's polypharmacy (cocaine, cannabis, tramadol >2x therapeutic range, benzodiazepam) caused substantial CNS depression and impairment. The coroner made recommendations to amend police policy to mandate lights/sirens…

forensic medicinetoxicologyproceduralcommunicationcocaine
VIChospital2017-02-20

Finding into death of Ms A

34y · Female·Global cerebral ischaemia secondary to mixed drug toxicity including a substance…

A 34-year-old woman with a 10-year history of heroin dependence died from mixed drug toxicity including heroin after injecting in a public toilet. She had engaged intermittently with methadone programs and expressed a re…

emergency medicineintensive caresystemheroin
VIC2022-03-28

Finding into death of Deva Rebecca Frijlink

42y · Female·Choking on a food bolus

Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…

speech pathologyemergency medicinecommunicationsystemdiazepam
SAhome2013-09-03

Coroner's Finding: KROMWYK Shane Andrew

38y · Male·mixed drug toxicity and arrhythmogenic right ventricular dysplasia

Shane Andrew Kromwyk, aged 38, died at home on 14 March 2009 while on home detention bail. Post-mortem examination revealed mixed drug toxicity (methadone, diazepam, alprazolam) combined with pre-existing arrhythmogenic …

general practiceaddiction medicinediagnosticmedicationmethadone
VIChome2023-05-29

Finding into death of Stuart John Noble

47y · Male·Multidrug toxicity (ethanol, quetiapine, baclofen, benzodiazepines)

Stuart Noble, 47, died from multidrug toxicity involving baclofen, quetiapine, benzodiazepines, and ethanol in an intentional overdose. He was prescribed baclofen off-label by his GP for alcohol use disorder despite it l…

general practiceaddiction medicinediagnosticsystembaclofen
VIChome2025-12-19

Finding into death of Narisha Faye Cash

41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)

Narisha Faye Cash, 41-year-old Aboriginal woman, died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called…

emergency medicinepsychiatrysystemcommunicationalcohol
NSW2019-07-05

Inquest into the death of Rebecca Maher

36y · Female·respiratory depression after loss of consciousness caused by mixed drug toxicity…

Rebecca Maher, a 36-year-old Aboriginal woman, died from respiratory depression caused by mixed drug toxicity (high levels of Alprazolam and Methadone) while detained as an intoxicated…

general practicepharmacydiagnosticmedicationalprazolam
VIChome2011-02-17

Finding into death of Michael William Gledhill

37y · Male·Mixed drug toxicity (heroin, methadone and diazepam) in a man with coronary arte…

…dule 8 drugs. These systemic failures created conditions enabling dangerous self-administration of multiple CNS depressants.

general practicepharmacologymedicationcommunicationheroin
SAcommunity2011-06-22

Coroner's Finding: TATCHELL Melissa Jay

28y · Female·bronchopneumonia complicating oxycodone toxicity

…l guidance and increasing absorption rate. Oxycontin combined with diazepam created additive respiratory depression. Poor medication governance at the residential facility allowed unclear administration. The death was li…

general practiceemergency medicinemedicationdiagnosticoxycodone
VIChome2025-07-28

Finding into death of Heather Ida Simone Calgaret

30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…

…intoxication (nausea, vomiting, drowsiness). While asleep that night, she likely experienced respiratory depression from the combination of buprenorphine, obesity, likely sleep apnoea, and quetiapine. Clinical lessons: (…

general practiceaddiction medicinemedicationdiagnosticbuprenorphine
WAcommunity2014-03-28

Inquest into the Death of Hayley DIAMOND

14y · Female·Acute cerebral hypoxia arising out of suffocation due to inhalation of toxic vap…

…and bronchopneumonia. Clinical lessons: volatile substance abuse poses immediate life-threatening risks via CNS depression, asphyxiation, and hypoxia. Early recognition of warning signs (unusual deodorant smell, behavio…

emergency medicineintensive carecommunicationsystemlynx deodorant spray

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