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VIChome2025-12-04

Finding into death of Raymond John Flaherty

57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…

Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…

addiction medicinegeneral practicesystemcommunicationheroin
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

A 60-year-old man with Type 2 diabetes and low mood died by hanging within 24 hours of being interviewed by police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide…

general practicepsychiatrycommunicationsystemfluoxetine
TAScommunity2025-12-03

Coroner's Finding: de-identified JI

54y · Male·Global hypoxic brain injury, cardiac arrest and blunt trauma to cervical spine

JI, a 54-year-old man with chronic schizophrenia, died from global hypoxic brain injury, cardiac arrest and cervical spine trauma following a fall onto a metal grate during an altercation with another resident at support…

psychiatrygeneral practicesystemdiazepam
TAShome2025-12-02

Coroner's Finding: de-identified DQ

54y · Female·mixed drug toxicity (methadone and diazepam)

A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…

general practicepharmacologydiagnosticmedicationmethadone
VICcommunity2025-11-28

Finding into death of Niels Gunther Btb: Becker

39y · Male·Unascertained

Niels Gunther Becker, a 39-year-old man with schizophrenia on stable antipsychotic therapy, disappeared while hiking in the Victorian High Country on 26 October 2019. His last communication was a text message sent at 11:…

psychiatrygeneral practicearipiprazole
VIChospital2025-11-28

Finding into death of Virginia Catherine Harris

60y · Female·Non-operative management of ruptured oesophagus (palliated)

Virginia Harris, a 60-year-old woman with epilepsy and intellectual disability living in supported accommodation, presented with abdominal pain on 18 March 2023. Initial examination by her GP showed mild tenderness that …

general practiceemergency medicine
SAhome2025-11-27

Coroner's Finding: Gifford, Paul Douglas

36y · Male·acute neck compression due to hanging

Paul Douglas Gifford, aged 36, died by hanging while on home detention bail. He had a long history of substance abuse (methamphetamine, opioids), mental health issues including borderline personality disorder, childhood …

psychiatryaddiction medicinemethamphetamine
SAhome2025-11-27

Coroner's Finding: Christian, Jake Nicholas

27y · Male·heroin toxicity

A 27-year-old man died from heroin toxicity while on home detention bail. He had a history of depression, anxiety, and substance use (cannabis, methamphetamine, heroin). During home detention, he was compliant, engaged w…

psychiatrygeneral practiceheroin
SAhome2025-11-27

Coroner's Finding: Brown, Logan Reece

25y · Male·hanging

Logan Brown, a 25-year-old man on home detention bail, died by hanging. He had a complex psychiatric history including borderline personality disorder, polysubstance use disorder, and chronic suicidal ideation dating fro…

psychiatrygeneral practicemethamphetamine
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

Annie Ng, aged 64, died from blunt force head trauma sustained in her home on 27 February 2024, with death occurring 9 March 2024 at Royal Melbourne Hospital. Her husband Chai, experiencing severe financial and psycholog…

oncologygeneral practicesystem
VIChome2025-11-18

Finding into death of JZA

65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …

A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…

geriatric medicineinfectious diseasessystemcommunicationpholcodine
WAcommunity2025-11-05

Inquest into the Death of Child WK (Name Subject to Suppression Order)

8y · Male·Streptococcus pyogenes and parechovirus infection

An eight-month-old boy in state child protection care died from Streptococcus pyogenes and parechovirus coinfection. He presented to regional ED on 2 September with fever and ear infection signs, then 4 September with mi…

general practiceemergency medicineamoxicillin
NSWcommunity2025-11-03

Inquest into the death of JF

60y · Female·multiple injuries

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…

psychiatrygeneral practicesystemmirtazapine
WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with c…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
QLDhospital2025-10-23

Inquest into the death of Kamalavati Sundar

86y · Female·Metastatic ovarian cancer (high-grade serous carcinoma)

An 86-year-old woman serving a life sentence died of metastatic ovarian cancer in palliative care. After diagnosis in April 2023, treatment was appropriately limited to symptom management given her advanced dementia, mak…

gynaecologypalliative careoxycodone
NSW2025-10-22

Inquest into the Death of Frank Dwayne COLEMAN

43y · Male·methadone toxicity

Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …

addiction medicinepsychiatrydiagnosticsystemmethadone
SAcommunity2025-10-17

Coroner's Finding: Hall, Robert Lloyd

66y · Male·multiple injuries sustained in motor vehicle collision

A 66-year-old cyclist was struck and killed from behind by a driver with left absolute homonymous hemianopia (left-sided visual field loss) who was not scanning to compensate for his disability. The driver had suffered a…

neurosurgeryneurologysystemcommunication
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
VIChome2025-10-16

Finding into death of Ms YPM

27y · Female·Hanging

Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…

psychiatryemergency medicinecommunicationdelayagomelatine
QLD2025-10-15

Inquest into the passing of ATJ

43y · Male·Hanging

A 43-year-old First Nations man died by hanging while remanded in custody for domestic violence offences. Initial risk assessments on admission were adequate—a psychologist appropriately assessed him as not requiring enh…

psychiatrypsychologycommunicationsystemamitriptyline
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