Coronial

99 results for medication misuse

SAhome2014-06-17

Coroner's Finding: KOLBIG Drew Robin

37y · Male·stab wound to the chest penetrating the heart

…ous compliance only under legal compulsion. Over the following 10 days, he exhibited non-compliance with medication, excessive alcohol consumption, and escalating psychotic symptoms including paranoid delusions that peop…

psychiatryoccupational therapydiagnosticcommunicationquetiapine
NSWhome2015-10-23

Inquest into the death of Christine Drinnan

45y · Female·Multi-drug toxicity

Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …

general practicepsychiatrydiagnosticmedicationmorphine
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…

general practiceaddiction medicinediagnosticcommunicationalprazolam
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

A 39-year-old woman with opioid dependency died from cardiac arrest caused by methadone toxicity. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…

addiction medicinegeneral practicediagnosticmedicationmethadone
TAShome2025-12-11

Coroner's Finding: de-identified SH

57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…

…ltiple psychiatric conditions. On the evening of her death, she consumed alcohol while taking prescribed medications including methadone, ibuprofen, and Panadol, and was found deceased the next morning. Post-mortem toxic…

general practicepharmacologymedicationmethadone
SAhome2007-11-09

Coroner's Finding: RANDALL Treenor Heather

50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)

…vices, delayed specialist psychiatric referral despite clear indications, inadequate monitoring of alcohol misuse (which significantly complicated her condition), and insufficient early engagement with cognitive-behaviou…

general practicepsychiatrycommunicationdelayquetiapine
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

…ependence was suboptimal. Recommended improvements include substance abuse assessment before prescribing medications with abuse potential, specialist referrals for complex cases, and regular monitoring of long-term analg…

general practicepain medicinemedicationcommunicationtramadol
TAShome2024-07-26

Coroner's Finding: Edwards, David and Nelda

David Edwards: disseminated lymphomatosis complicating large B-cell lymphoma. Ne…

… indication, professional consultation, or her informed consent. Stephen Edwards had obtained injectable medications from a locum GP (Dr F.) on 1 March 2016 by misrepresenting his father's condition and requesting pallia…

general practicepalliative caremedicationcommunicationmorphine
VIChome2012-02-15

Finding into death of James

24y · Male·Combined drug toxicity (morphine and diazepam)

…rescription shopping across 19 doctors and 32 pharmacies over three years, obtaining large quantities of medications while concealing his attendance at multiple providers. Depression, anxiety, and prescription drug addic…

general practicepsychiatrysystemcommunicationmorphine
QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

…nce abuse on child safety and the need for better systems to identify and intervene in prescription opioid misuse.

paediatricsgeneral practicemedicationdiagnosticmorphine
VICcommunity2024-08-07

Finding into death of Jason

50y · Male·Neck compression secondary to hanging

Jason, age 50, was found deceased by hanging at a footbridge in Kerang, Victoria on 18 October 2021, following an incident of family violence perpetrated by him against his partner 'P'. The coroner's investigation identi…

general practicepsychiatrysystemcommunicationvenlafaxine
WAmental health- 11 April 2014

Inquest into the Death of Aaron Luke PRISGROVE

32y · Male·ligature compression of the neck (hanging)

Aaron Luke Prisgrove, a 32-year-old man with depression, alcohol abuse, and acromegaly, died by hanging on 12 July 2011, shortly after involuntary admission to Graylands Hospital's Smith Ward. He had presented to Tom Pri…

psychiatryemergency medicinecommunicationsystemparacetamol/codeine
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

…services discharged NLU with incomplete risk assessment despite documented family violence history, poor medication compliance, psychotic symptoms, and substance abuse; (2) NLU's diagnosis remained unclear (alcohol abuse…

psychiatryemergency medicinediagnosticcommunicationolanzapine
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks …

psychiatryintensive caresystemdelayaripiprazole depot
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

…rescription monitoring) was not yet available, the general practitioners who prescribed Schedule 4 and 8 medications to LI on a one-off basis missed critical opportunities to intervene by checking available resources lik…

general practicepsychiatrymedicationdiagnosticcodeine
VICcommunity2014-04-07

Finding into death of Kirk Ardern

32y · Male·Multiple drug toxicity (including heroin)

Kirk Steven Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failure…

general practiceaddiction medicinemedicationcommunicationheroin
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

…ors warranting immediate evacuation. Paracetamol overdose was likely ingested 1-3 November from diverted medication; acetylcysteine antidote effectiveness was diminished by the time of hospital arrival. Systemic failures…

emergency medicinetoxicologydiagnosticcommunicationparacetamol
WAhome2016-02-10

Inquest into the Death of Shayne Andrew BERRY

44y · Male·Combined drug effect (oxycodone and benzodiazepines)

…ycodone from two different doctors on the same day (15 and 23 November 2012) at different pharmacies, then misused the medication intravenously in combination with his regular benzodiazepines. He had reduced opioid toler…

general practicepharmacologysystemcommunicationoxycodone
WAhome2016-02-10

Inquest into the Death of Daniel James HALL

26y · Male·Multiple drug toxicity and bronchopneumonia

Daniel James Hall, aged 26, died on 31 July 2010 from multiple drug toxicity and bronchopneumonia after consuming approximately 10-12 OxyContin tablets over 24 hours, vastly exceeding the prescribed dose of one tablet ev…

anaesthesiaENT surgerycommunicationsystemoxycodone

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