Coronial

135 results for polysubstance use disorder

VICcommunity2023-02-16

Finding into death of Shane Ronald Dennis Brown

30y · Male·Methamphetamine toxicity in the setting of a stabbing

Shane Ronald Dennis Brown, a 30-year-old man with a long history of methamphetamine use, died on 20 April 2021 following a physical altercation at a residential address in Melton, Victoria. Autop…

forensic medicineemergency medicinemethamphetamine
QLD2025-10-29

Inquest into the death of Selesa Tafaifa

44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…

…logical distress from being denied phone calls, and possible intermittent asphyxia. The coroner found the cause 'not determined' as relative contributions could not be established. Clinical lessons include: recognising …

forensic medicineemergency medicineproceduralsystemmixtard 30/70 insulin
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

…nging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms. A key clinical lesson emerges …

psychiatrygeneral practicediagnosticcommunicationolanzapine
VICprison2020-12-23

Finding into death of Gary Hietanen

45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)

A 45-year-old male prisoner died in custody from combined drug toxicity after ingesting methadone, amitriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to…

emergency medicinecardiologycommunicationsystemmethadone
VIChome2023-07-28

Finding into death of Jackson Desmond David Stawicki

24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm

Jackson Stawicki, 24, died from haemorrhagic shock following a sharp force injury to his left arm while intoxicated with multiple illicit substances. He presented to the ED three times within 24 hours (4-5 September 2020…

emergency medicinepsychiatrycommunicationsystemflualprazolam
WA2008-07-07

Inquest into the Death of Kirsty Anne Slater

24y · Female·Ligature compression injury to the neck (hanging)

Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantl…

psychiatryintensive carecommunicationsystemmorphine
WAcommunity2018-07-12

Inquest into the Death of Shane Christopher FLANDERS

29y · Male·unknown, probably immersion

Shane Flanders, a 29-year-old man with a complex psychiatric history including personality disorder, substance abuse, previous suicide attempt, and drug-induced psychosis, disappeared on 28 January 2016 af…

psychiatryemergency medicinediagnosticcommunicationdextroamphetamine
QLD2019-09-06

Blair, Colin Wayne

44y · Male·Hanging

Colin Wayne Blair, a 44-year-old Aboriginal man with a history of mental illness and substance use, died by hanging in the High Dependency Unit of Brisbane Correctional Centre on 13 November 2015. He was on…

psychiatrypsychologycommunicationsystem
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

…s against police, but identified Peter's untreated mental health conditions (PTSD, borderline personality disorder, chronic suicidality), substance use, and easy access to a realistic gel blaster as contributing factors.…

emergency medicinetrauma surgerysystemmethamphetamine
VIC2016-11-22

Finding into death of Mahmoud Taiba

36y · Male·Hanging

A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3…

psychiatrycorrectional healthcommunicationsystemolanzapine
VICcommunity2019-06-18

Finding into death of Yara Sturak Mignon

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

…ed irreversible hypoxic brain injury and died four days later. This case highlights the concentrated heroin use and associated harms in North Richmond, particularly at non-residential locations. The coroner examined the…

emergency medicineintensive caresystemheroin
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and my…

psychiatrycardiologysystemcommunicationquetiapine
VIChome2020-06-12

Finding into death of Daniel Isaac Semple

39y · Male·Multiple drug toxicity (methadone, diazepam, oxazepam, carbamazepine, levetirace…

…ess suitability for unsupervised dosing, and failure to detect or act on evidence of methadone injection misuse. The prescribing GP failed to implement planned benzodiazepine tapering and continued takeaway dosing despi…

general practiceaddiction medicinediagnosticmedicationmethadone
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatien…

psychiatryaddiction medicinemedicationproceduralmethadone
VICmental health2015-07-08

Finding into death of David Allan D'Angelo

30y · Male·Heroin toxicity

David D'Angelo, a 30-year-old Aboriginal man with schizophrenia and polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic r…

psychiatryemergency medicinesystemdelayheroin
VIC2015-11-20

Finding into death of Dean Christopher Courts

33y · Male·Pulmonary thromboembolism

…ence at Port Phillip Prison, died from pulmonary thromboembolism on 5 July 2014. No pre-disposing medical cause was identified; immobility during 13 months in protective custody likely contributed, along with possible g…

correctional healthtramadol
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 thromboembo…

psychiatryintensive caresystemdelayaripiprazole depot
WAhome2021-11-29

Inquest into the Death of Ly Minh TONG

38y · Male·Multiple gunshot wounds

A 38-year-old man with a history of methamphetamine use and mental health issues, subject to a violence restraining order, assaulted his father at home. The father…

psychiatrytoxicologycommunicationsystemmethamphetamine
QLDhospital2016-11-23

SPB - Non-inquest findings

36y · Male·hanging

A 36-year-old man with 15-year history of paranoid schizophrenia and polysubstance abuse presented to hospital after violent behaviour toward his father while intoxicated. Despite polic…

psychiatryemergency medicinediagnosticcommunicationdiazepam
ACThospital2023-03-08

Inquest into the death of Brontë Haskins

23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…

…cases with minimal resources), delayed CADAS assessment (scheduled one week post-release despite known drug use and suicide risk), failure to arrange mental health bail conditions despite documented suicidality in custo…

psychiatryemergency medicinesystemdelayheroin

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