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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
NSWcommunity2020-02-27

Inquest into the death of DP

45y · Male·gunshot wound to the chest

DP, a 45-year-old with a history of methylamphetamine use and drug-induced psychosis/schizophrenia, attended Quakers Hill Police Station on 19 January 2016 with a knife intending to provoke police into shooting him. His …

psychiatryemergency medicinemethamphetamine
NSWhospital2020-02-14

Inquest into the death of Tristan Naudi

23y · Male·Acute cardiac arrhythmia in 3,4-methylenedioxymethylamphetamine (MDMA) intoxicat…

Tristan Naudi, 23, died from acute cardiac arrhythmia during MDMA intoxication while being restrained prone at hospital. Police appropriately placed him in a police vehicle after finding him violently agitated at home. A…

emergency medicinetoxicologysystemdelayMDMA
NSW2020-02-13

Inquest into the death of LP

34y · Male·Foreign body aspiration

A 34-year-old man died by foreign body aspiration while in custody at a correctional centre, three days after arrest for a serious violent crime. He fashioned an airway obstruction from toilet paper and meal pack plastic…

psychiatrycorrectional healthsystemcommunication
SAhome2020-02-10

Coroner's Finding: DAILLER Graziella and MUIR Dion Wayne

48y · Female and male·Ms Dailler: blunt head trauma and multiple sharp force injuries including stab w…

This inquest examined the deaths of two people in a violent domestic relationship. Ms Dailler, aged 48, was killed by her partner Mr Muir through blunt force trauma and stab wounds. Mr Muir subsequently died by suicide. …

emergency medicineforensic medicinecommunicationsystemalcohol
NSWmental health2020-02-07

Inquest into the death of Chella Leijten

57y · Female·metastatic lung carcinoma

Chella Leijten, aged 57, died from metastatic lung carcinoma on 21 March 2018 while an involuntary patient in a palliative care unit. She had longstanding schizoaffective disorder requiring repeated psychiatric admission…

psychiatrypalliative care
WA2020-02-05

Inquest into the Death of Tania Marie HODGKINSON

48y · Female·Ligature compression of the neck (hanging)

Tania Marie Hodgkinson, a 48-year-old Aboriginal woman, died by suicide via ligature compression while remanded at Bandyup Women's Prison on 23 March 2017. She had been admitted with heroin withdrawal symptoms, grief fro…

psychiatrypsychologycommunicationsystemheroin
NSW2020-02-05

Inquest into the death of Francis McCann

49y · Male·complications of a cervical spine injury

Francis McCann, a 49-year-old man in custody with a history of schizophrenia, anxiety, and self-harm, fell from his bed during sleep on 24 September 2017, sustaining a serious cervical spine injury (C4-C5 with canal sten…

orthopaedic surgeryneurosurgery
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

Jose da Silva, a 34-year-old man with a history of schizophrenia and problematic alcohol use, disappeared on 30 April 2017 from Perth, Western Australia. The coroner found he died on or about that date, most likely from …

psychiatrygeneral practiceolanzapine
VIChome2020-01-31

Finding into death of X Y

27y · Female·Combined drug toxicity

XY, a 27-year-old woman, died from combined drug toxicity on 21–22 December 2016 at a friend's house in Melbourne. She had a history of opioid use, depression, and anxiety following a violent crime. She was enrolled in r…

general practiceaddiction medicinesystemmethamphetamine
VICpsychiatric inpatient unit2020-01-31

Finding into death of Damon Brenden Amiet

25y · Male·Injuries sustained when struck by a train (suicide)

Damon Brenden Amiet, a 25-year-old with schizoaffective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serio…

psychiatryemergency medicinecommunicationsystemolanzapine
VIChome2020-01-29

Finding into death of Caitlin-Lei Alaya

44y · Female·Combined drug toxicity (elevated pregabalin, temazepam, oxazepam, ibuprofen, mel…

Caitlin-Lei Alaya, a 44-year-old woman with fibromyalgia, PTSD, depression and suicidal ideation, died from combined drug toxicity (elevated pregabalin, temazepam, ibuprofen, meloxicam). She survived a suicide attempt on…

general practiceemergency medicinemedicationsystempregabalin
NSW2020-01-24

Inquest into death of MW

52y · Male·Hanging

MW, a 52-year-old man awaiting extradition to the United States, died by hanging in Parklea Correctional Centre on 5 May 2017. Upon reception screening, he denied suicidal ideation and scored 21/50 on the Kessler 10 scre…

general practicepsychiatrymirtazapine
VIC2020-01-15

Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). …

oral and maxillofacial surgeryemergency medicinecommunicationsystemmethadone

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