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VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…

psychiatrygeneral practicecommunicationsystemphentermine
SAhospital2020-01-10

Coroner's Finding: PLAYFORD Aldona Mariana

84y · Female·sepsis and cardiac failure in a woman with hypertensive ischaemic and valvular h…

Aldona Mariana Playford, an 84-year-old woman with extensive medical comorbidities including ischaemic heart disease, chronic renal failure, and severe biventricular dysfunction, died of sepsis and cardiac failure. She w…

cardiologypsychiatryfurosemide
SAhospital2020-01-10

Coroner's Finding: KNOWLES Edward James

80y · Male·inanition complicating end stage dementia

An 80-year-old man with end-stage dementia died from inanition (severe malnutrition/dehydration) while subject to Mental Health Act inpatient treatment orders. He had been admitted after becoming aggressive at home due t…

psychiatrygeriatric medicineantipsychotic medication
SAhospital2020-01-10

Coroner's Finding: FIORETTI Louisa Jill Josephine

19y · Female·2,4-dinitrophenol toxicity

A 19-year-old woman died from 2,4-dinitrophenol (DNP) toxicity after intentionally ingesting approximately 50 x 250mg capsules purchased online. She presented to Flinders Medical Centre with an Inpatient Treatment Order …

toxicologyemergency medicine2,4-dinitrophenol
SAhospital2020-01-10

Coroner's Finding: BICKLEY Jon

79y · Male·ischaemic heart disease complicating chronic obstructive airways disease

Jon Bickley, aged 79, died of ischaemic heart disease complicating chronic obstructive airways disease while subject to an Inpatient Treatment Order at Flinders Medical Centre. He presented with acute delirium and agitat…

geriatric medicinepsychiatryfentanyl
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
VIChome2020

Finding into death of Julian Victor Charles Bareuther

68y · Male·PLASTIC BAG AND NITROGEN GAS ASPHYXIA

68-year-old man with terminal, inoperable pancreatic cancer died by asphyxiation using a plastic bag and nitrogen gas. He sought access to Voluntary Assisted Dying (VAD) through his GP, Dr C., who assessed him as mentall…

general practicepalliative caresystem
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient…

psychiatrycardiologysystemcommunicationquetiapine
NSWhome2019-12-20

Inquest into the deaths of TC and SN

Female·Hanging

This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…

paediatricspsychiatrycommunicationsystem
VICmental health2019-12-17

Finding into death of Thien Cong Pham

27y · Male·ligature strangulation

A 27-year-old male with treatment-resistant schizophrenia died from ligature strangulation by a co-patient at a secure forensic mental health facility. The deceased had multiple admissions for medication non-compliance a…

psychiatrycorrectional healthsystemdelayclozapine
VIChome2019-12-13

Finding into death of Kyle Horne

19y · Male·Hanging

Kyle Horne, a 19-year-old with high-functioning autism, died by hanging on 15 March 2018 following relationship breakdown. He presented to his GP on 8 March 2018 requesting a Mental Health Care Plan, citing relationship …

general practicepsychiatrydiagnostic
TAScommunity2019-12-06

Coroner's Finding: McInerney, Robert Edward

48y · Male·gunshot wounds to the right thigh and abdomen with fatal hemorrhage

A 48-year-old man with severe chronic pain, alcohol dependence, and mental health issues called police stating he was armed with knives and wanted to be shot. Despite being extensively supported by health services that d…

psychiatryemergency medicinealcohol
NSWmental health2019-12-04

Inquest into the death of Mitchell FLOOD-SMITH

23y · Male·Multiple injuries sustained following collision with a train

A 23-year-old man with a history of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2…

psychiatryparamedicinecommunicationsystemrisperidone
SAhospital2019-12-03

Coroner's Finding: TAEGER Luke Victor

89y · Male·pneumonia on a background of advanced Parkinson's disease and dementia

An 89-year-old man with advanced Parkinson's disease and dementia died of aspiration pneumonia following hospital admission for behavioural management. He was subject to an Inpatient Treatment Order and required chemical…

geriatric medicinepsychiatrythyroxine
SAhospital2019-11-30

Coroner's Finding: FRANKLIN Allen Henry

83y · Male·aspiration pneumonia and delirium complicating surgery for left total knee repla…

An 83-year-old man with dementia and ischaemic heart disease underwent elective left total knee replacement under spinal anaesthesia to avoid general anaesthesia, as advised by geriatrician. Despite optimal anaesthetic t…

orthopaedic surgerygeriatric medicine
NSWmental health2019-11-29

Inquest into the death of Harold EDWARDS (a pseudonym)

49y · Male·Hanging

A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …

psychiatrydiagnosticcommunicationtemazepam
VIChome2019-11-28

Finding into death of Sonya Szala

49y · Female·Anorexia

Sonya Szala, 49, died from anorexia nervosa after suffering severe metabolic derangement and extreme emaciation. She became a recluse following her mother's death in 2016 and progressively deteriorated both physically an…

emergency medicinepsychiatrydelaybisacodyl
NSWmental health2019-11-22

Inquest into the death of David Dungay

29y · Male·cardiac arrhythmia

David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…

psychiatryemergency medicineproceduralcommunicationmidazolam
QLD2019-11-21

Gavenor, Ashley Glenfield

48y · Male·Coronary atherosclerosis and minor trauma

Ashley Glenfield Gavenor, a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following a brief altercation with anoth…

cardiologypsychiatryaspirin
NSWhospital2019-11-21

Inquest into the death of Ross MARTIN

56y · Male·acute pentobarbitone toxicity

Ross Martin, a 56-year-old man with a long history of depression, died from acute pentobarbitone (Nembutal) toxicity obtained online, combined with toxic levels of zopiclone, less than two weeks after premature discharge…

psychiatrygeneral practicediagnosticcommunicationpentobarbitone

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