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VICcommunity2020-11-27

Finding into death of Nicholas Daniel Ficarra

26y · Male·unascertained; suspected suicide by firearm

Nicholas Daniel Ficarra, aged 26, disappeared on 14 January 2012 from his family farm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 200…

psychiatrygeneral practicesystemdelayheroin
NSWmental health2020-11-27

Inquest into the death of JP

46y · Female·hypoxic brain injury due to hanging

A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…

psychiatryemergency medicinecommunicationprocedural
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

A 68-year-old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following t…

psychiatrycardiologydiagnosticcommunicationolanzapine
VICmental health2020-11-25

Finding into death of Thi Qui Tran

53y · Female·Heatstroke

Thi Qui Tran, a 53-year-old woman with schizophrenia on antipsychotic medications (zuclopenthixol and olanzapine), died of heatstroke on 9 February 2018 after collapsing on a street during extended unescorted leave from …

psychiatryintensive caresystemdelayzuclopenthixol
TAScommunity2020-11-23

Coroner's Finding: Golding, Laura Rebecca

51y · Female·drowning

Laura Golding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay withou…

psychiatrygeneral practicesystemdelay
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…

general practiceforensic medicinecommunicationsystemoxycodone
NSWcommunity2020-11-16

Inquest into the death of D B

39y · Male·Self-inflicted death by hanging

A 39-year-old man with longstanding Bipolar I Disorder died by hanging on 28 December 2017, shortly after police attended a domestic disturbance at his mother's home. He had expressed suicidal ideation to his treating ps…

psychiatryemergency medicinecommunicationsystem
NSWmental health2020-11-11

Inquest into the death of G Y

41y · Male·ligature strangulation

A 41-year-old man with intellectual disability, autism spectrum disorder, and psychosis died by ligature strangulation using his shoelaces in an acute mental health unit. He had been admitted involuntarily following esca…

psychiatryemergency medicinerisperidone
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents as both perpetrator and victim in relationships, leading to…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

Jessica Morgana Wilby, aged 45, a highly accomplished Principal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September…

psychiatrypsychologysystemcommunicationantidepressants
VICaged care2020-11-06

Finding into death of VA

73y · Female·Combined effects of congestive cardiac failure, coronary artery atherosclerosis …

VA, a 73-year-old woman with mental health conditions and cardiac disease, died from congestive cardiac failure, coronary atherosclerosis, and cardiomegaly while an inpatient in a psychiatric unit. She had recently been …

psychiatryintensive caremetaraminol
NSWhome2020-11-06

Inquest into the death of Bosco Toufalous

35y · Male·Combined effects of positional asphyxiation and intoxication

A 35-year-old man with severe alcohol use disorder died from positional asphyxiation while intoxicated. With a blood alcohol level of 0.293 g/100mL, he fell near stairs outside a neighbour's unit, landing with his head a…

forensic medicinetoxicologyalcohol
WAcommunity2020-11-05

Inquest into the Suspected Death of Paul Clifford YORK

45y · Male·unascertained

Paul Clifford York, 45, disappeared from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdos…

psychiatrygeneral practicediagnosticsystemmirtazapine
WAprison2020-11-04

Inquest into the Death of Damien PURNELL

47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…

Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…

emergency medicineintensive caresystemmethadone
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…

psychiatryemergency medicinecommunicationsystemquetiapine
SAhospital2020-11-03

Coroner's Finding: WHISKEY Louise Kitty

51y · Female·community acquired pneumonia

Louise Kitty Whiskey, a 51-year-old Aboriginal woman with chronic alcohol misuse, cirrhosis, and recurrent respiratory infections, died from community-acquired pneumonia at Royal Adelaide Hospital. She was admitted on 23…

intensive carepsychiatrysystemnoradrenaline
SAhospital2020-11-03

Coroner's Finding: MARSHALL Daryl Grant

61y · Male·hospital acquired pneumonia complicating aorto-femoral bypass surgery for periph…

A 61-year-old man with peripheral vascular disease, alcohol dependence, and heavy smoking history underwent aorto-femoral bypass surgery. Post-operatively he developed hospital-acquired pneumonia, delirium from alcohol w…

vascular surgeryintensive care
SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

75-year-old woman with end-stage mixed dementia (vascular and Alzheimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and beha…

psychiatrygeriatric medicinehydromorphone
TAS2020-11-02

Coroner's Finding: Mikl, Petr

72y · Male·haemoperitoneum complicating spontaneous perforation of peritoneal varix in the …

Petr Mikl, a 72-year-old man held in secure mental health custody, died from haemoperitoneum due to spontaneous perforation of a peritoneal varix secondary to portal hypertension caused by portal vein thrombosis and hepa…

psychiatrygastroenterology
TAShome2020-11-02

Coroner's Finding: Besgrove, Trevor Scott

46y · Male·cause of death cannot be determined

Trevor Besgrove, a 46-year-old man with complex mental health issues including borderline schizophrenia, depression, and a history of trauma and substance use, was found deceased in his Bicheno home after an estimated tw…

psychiatrypsychologysystemprescribed medications

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