Coronial

181 results for poor medication compliance

SAhospital2026-02-26

Coroner's Finding: Lowery, Nahuel Sebastian

41y · Male·Acute liver failure with contributing Castleman's disease

… with HIV and Castleman's disease died from acute liver failure while on home detention. He had variable compliance with antiretroviral therapy, exacerbated by amphetamine use disorder and mental health issues. During de…

infectious diseasesintensive careantiretroviral therapy
VIChome2021-08-03

Finding into death of V T

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

… family violence incident. Her son had a 20-year history of schizophrenia and schizoaffective disorder with poor medication compliance, documented aggression toward his mother, and repeated threats to kill her. Family me…

psychiatrygeneral practicecommunicationsystem
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

…s present with altered consciousness or unusual sedation, particularly before administering psychotropic medications; (2) staff managing residents with both mental health conditions and substance use disorders require ap…

psychiatryaddiction medicinecommunicationsystemheroin
TAScommunity2020-08-07

Coroner's Finding: Delios, Voula 2020 TASCD 458

63y · Female·Multiple stab wounds to neck and chest

…d); failure to invoke Mental Health Act compulsory treatment orders despite clear need for antipsychotic medication compliance; inadequate resources and bed capacity in forensic mental health (Wilfred Lopes Centre underf…

psychiatrycorrectional healthdiagnosticsystemolanzapine
VICcommunity2016-09-06

Finding into death of Antonio D'Augello

63y · Male·Drowning

… channel four days after discharge from emergency care. He had deteriorated after stopping antipsychotic medication in March 2016. During a collapse on 28 April, he was taken to Goulburn Valley Health ED where he was ass…

psychiatryemergency medicinecommunicationdelayolanzapine
NSWhome2017-01-13

Inquest into the death of EG and JB

Unknown·Electrocution

…ive treatment to continue caring for his wife EG, who had chronic paranoid schizophrenia managed without medication despite psychiatric care. Concerned about EG facing involuntary psychiatric admission after his death, J…

cardiologyoncologyrisperidone
TAShospital2023-04-13

Coroner's Finding: Leader, Andrew

60y · Male·sepsis/leg cellulitis with peripheral oedema and congestive cardiac failure in t…

…tted to hospital on 17 November 2021, he exhibited significant psychiatric symptoms including delusions and poor insight. Despite appropriate clinical management by hospital staff, he consistently refused essential treat…

general medicinepsychiatry
NThome2003-12-19

Inquest into the death of Sunjay Chandra

25y · Male·hanging (self-inflicted)

…d detailed observations of psychotic symptoms including auditory hallucinations, disorganized behavior, and poor hygiene, but treating clinicians did not arrange earlier intervention despite multiple parental communicati…

psychiatrypsychologycommunicationsystemclozapine
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

Gheorghe Gruici, a 71-year-old life-sentenced prisoner, died of organ failure from chronic renal failure, infective endocarditis, and chest infection. Over 15 years in custody, he developed multiple comorbidities includi…

general medicinenephrologyomeprazole
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

…ccurred over 24+ hours; (2) transfer authorised without personal psychiatric assessment of the patient; (3) poor record-keeping regarding medication administration, making it unclear whether antipsychotics were given des…

psychiatryemergency medicinecommunicationsystemolanzapine
QLDhospital2009-11-20

Johnston, Margaret Allan

82y · Female·Complications from hypoglycaemic brain damage and cerebral vascular accident

…e expert evidence, the coroner concluded insulin was administered on two separate occasions, likely as a medication error rather than malice. She suffered irreversible hypoglycaemic brain damage and concurrent cerebral s…

anaesthesiaendocrinologymedicationsysteminsulin
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

Ashley Paull, a 49-year-old Aboriginal man with schizophrenia, died after being struck by a truck while walking along the Pacific Highway following his release from police custody. He had been stopped for a positive road…

psychiatryemergency medicinecommunicationsystemmethamphetamine
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

…ug-induced psychosis in November 2019. After discharge, despite mental health support and anti-psychotic medication, his mental state deteriorated with increased paranoia, substance use, and suicidal ideation. On the nig…

rheumatologyallergy and immunologycommunicationsystemoxycodone
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

…ing on hourly observations and deteriorating mental state that evening (agitation, tremors after ceasing medication for ECT), he was allowed accompanied leave with his partner. The hospital's therapeutic leave policy was…

psychiatrysystemcommunicationcitalopram
NSWhospital2017-08-22

Inquest into the death of Tyson MATTHEWS

30y · Male·external neck compression due to hanging

… Contact with the mother to confirm her ability to provide support was documented. (4) The antipsychotic medication (paliperidone) was appropriate and unlikely to have contributed to his depression. The coroner found no …

psychiatryemergency medicinepaliperidone
WAhospital2019-04-04

Inquest into the Death of Maris KUGIS

68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease

…ncreatic cancer) may underlie apparently psychiatric symptoms like hyponatraemia. The combination of non-compliance and pain-driven behaviour severely hindered optimal medical management.

psychiatryrespiratory medicinehaloperidol
VIChospital2025-02-26

Finding into death of CFT

78y · Female·Bronchopneumonia

…ultiple agencies (Mecwacare, carers, GP, OPA) documented concerns about neglect from 2017 onwards including poor continence care, malnutrition, weight loss, inadequate hygiene, and failure to attend medical appointments.…

geriatric medicinegeneral practicediagnosticsystem
VIC2023-10-30

Finding into death of Darren James Fielding

29y · Male·Methadone toxicity

…ord-keeping in breach of policies and noted that while nursing staff maintained they gave the correct dose, poor documentation created an impediment to investigation. Key lessons: rigorous Schedule 8 compliance, contempo…

pharmacycorrectional healthmedicationsystemmethadone
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

… the Medical Sub-acute Unit. Over subsequent days his condition deteriorated with multiple falls and non-compliance with insulin. On 10 May he finally agreed to transfer to ACRU where he was assessed as terminal, transit…

geriatric medicinepalliative careantiviral medication
VIChome2014-03-06

Finding into death of Kylie Jane Fowler

36y · Female·Effects of Fire

…anuary 2011. Ms Fowler had five involuntary psychiatric admissions but consistently rejected treatment, had poor medication compliance, and was never engaged with a GP after discharge from mental health services in Septe…

psychiatrygeneral practicecommunicationsystemrisperidone
145610

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