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VICcommunity2020-05-07

Finding into death of Mark Beames

44y · Male·Unascertained

Mark Beames, a 44-year-old Aboriginal man with epilepsy, acquired brain injury, and alcohol dependency, disappeared on 4 September 2014 from Swan Hill, Victoria. He had recently been discharged from hospital after self-d…

psychiatryneurologydiazepam
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

23y · Male·Neck compression as a result of hanging

Jonathon Hogan, a 23-year-old Aboriginal man of Wiradjuri, Ngiyampaa and Murrawarri descent, died by hanging at Junee Correctional Centre on 3 February 2018 while serving remand. He had longstanding schizophrenia with pr…

psychiatrygeneral practicediagnosticcommunicationolanzapine
VICcommunity2020-05-01

Finding into death of Joelene Therese Dowden

37y · Female·Hypoxic ischaemic brain injury complicating aspiration of gastric contents

Joelene Dowden, 37, died from hypoxic-ischaemic brain injury following aspiration of gastric contents. She presented at Alfred Hospital ED on 9 July 2017 with erratic behaviour, then went to a tram stop where she express…

emergency medicineintensive caredoxylamine
SAmental health2020-04-30

Coroner's Finding: BENN John Harold

70y · Male·ischaemic heart disease

A 70-year-old man with ischaemic heart disease, dementia, diabetes, hypertension and aortic stenosis died suddenly of acute myocardial infarction while in compulsory mental health detention. He had fallen the previous mo…

psychiatrygeriatric medicine
VIChome2020-04-23

Finding into death of Baillee Petra Schneider

25y · Female·Compression of the neck

Baillee Schneider, a 25-year-old woman, died by suicide via neck compression while intoxicated. She had a history of substance misuse (cocaine, alcohol), anxiety treated with Zoloft, and was taking alprazolam. On the mor…

psychiatrytoxicologyalcohol
VIChospital2020-04-23

Finding into death of John Alexander King

60y · Male·Mixed drug toxicity

A 60-year-old man with schizophrenia and depression presented to Maroondah Hospital ED with acute psychotic symptoms after stopping his antipsychotic medication (trifluoperazine) due to manufacturer discontinuation. He w…

emergency medicinepsychiatrysystemcommunicationtrifluoperazine
VICaged care2020-04-22

Finding into death of Dorothy May Nelson

81y · Female·Complications of choking on a food bolus in a woman with dementia

Dorothy May Nelson, an 81-year-old woman with dementia, died from complications of choking on a food bolus at an aged care facility. She was served diced beef in casserole (approximately 4cm bolus found at autopsy, despi…

geriatric medicinepsychiatrydiagnosticproceduralmorphine
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

Jesse Bird, a 32-year-old Torres Strait Islander veteran, died by suicide in June 2017 after struggling to navigate the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, develop…

psychiatryparamedicinesystemcommunicationduloxetine
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

Darren Brandon died by hanging in prison on 10 June 2018, two days after arriving at Melbourne Assessment Prison. He was a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and histo…

psychiatryforensic medicinecommunicationsystemoxycodone
VIC2020-04-06

Finding into death of Robert James Lawerence

29y · Male·Shotgun wound to the head

Robert James Lawrence, a 29-year-old man with complex mental health needs including ADHD, depression, anxiety, Tourette's syndrome, and borderline personality traits, died from a self-inflicted shotgun wound. He held a C…

psychiatrypsychologycommunicationsystem
WAhospital2020-04-02

Inquest into the Death of Valerie KELLY

67y · Female·bronchopneumonia and acute liver failure on a background of liver cirrhosis and …

Valerie Kelly, a 67-year-old woman with cirrhosis, hepatocellular carcinoma, and multiple comorbidities, died at Royal Perth Hospital from bronchopneumonia and acute liver failure. She was in custody at Bandyup Women's P…

hepatologygastroenterologycommunicationsystemolanzapine
WAaged care2020-03-27

Inquest into the Death of Laureen Kaye REILLY

54y · Female·combined drug toxicity (heroin, morphine, cannabis, and prescription medications…

Laureen Kaye Reilly, aged 54, died from combined drug toxicity involving heroin, cannabis, and prescription medications including antipsychotics and mood stabilizers. She had complex mental health disorders, acquired bra…

psychiatrygeneral practiceheroin
TAShome2020-03-23

Coroner's Finding: Szemes, Kim Leonie Maree

59y · Female·Unable to determine - body too decomposed at autopsy

Mrs Szemes, a 59-year-old woman with longstanding mental health issues living alone, was found deceased after an interval of approximately 5 months. On 28 May 2018, police attended her home after welfare concerns and cal…

paramedicinepsychiatrycommunicationsystem
WAhospital2020-03-20

Inquest into the Death of Norman Alexander HAZELGROVE

73y · Male·metastatic carcinoma of the lung with palliation

Norman Hazelgrove, a 73-year-old prisoner, died from metastatic lung carcinoma in September 2017. Early in his imprisonment (2013), a chest X-ray showed COPD but this diagnosis was not formally documented or managed desp…

respiratory medicineoncologydiagnosticsystemantihypertensive medication
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicidal ideation, and opioid dependence. On 1 July …

psychiatrysystemcommunicationcitalopram
NSWhome2020-03-16

Inquest into the death of Christina BURGESS

50y · Female·unknown

Christina Burgess, aged 50, was found deceased in her mother's home in August 2018, having likely died between May and August 2018. Autopsy examination could not establish a cause of death due to advanced decomposition. …

psychiatrygeneral practicesystemcommunication
VICmental health2020-03-13

Finding into death of PATIENT A

35y · Female·mixed drug toxicity (fentanyl, morphine, clozapine and aripiprazole)

A 35-year-old woman with schizoaffective disorder, opiate use disorder, and amphetamine use disorder died from mixed drug toxicity (fentanyl, morphine, clozapine, and aripiprazole) after absconding from an inpatient ment…

psychiatryfentanyl
WAcommunity2020-03-04

Inquest into the Suspected Death of Gordon COLLEY

38y · Male·Hallucination, dehydration and exposure, exacerbated by untreated mental illness…

Gordon Colley, a 38-year-old Aboriginal man from the Marto people, disappeared on 7 December 1997 from Mundiwindi Station near Newman, Western Australia. He was known to have mental health issues requiring anti-psychotic…

psychiatrygeneral practicehaloperidol
NSWaged care2020-03-03

Inquest into the death of Hazel BROCKETT

86y · Female·complications of femoral, radial and ulnar fractures; antecedent cause Alzheimer…

86-year-old Hazel Brockett died from complications of fractures inflicted by a fellow dementia-affected resident in a locked Memory Support Unit (aged care dementia facility). Over months prior, the other resident demons…

geriatric medicinegeneral practicecommunicationdiagnosticbuprenorphine
VICcommunity2020-02-28

Finding into death of Robb Thomas Lawson

48y · Male·unascertained

Robb Thomas Lawson, a 48-year-old man with a long history of mental illness including depression, anxiety, paranoia and multiple suicide attempts, disappeared in July 2007 after declining psychiatric care. He had been ma…

psychiatrycommunicationolanzapine

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