Coronial

116 results for drug misuse

SAhome2002-09-06

Coroner's Finding: KEN Kunmanara (2)

27y · Male·hydrocarbon inhalation

This inquest involved three deaths from petrol inhalation (1999-2001) on the Anangu Pitjantjatjara Lands. All three deceased were chronic sniffers (10+ years) who died from respiratory depression/asphyxia with distinctiv…

forensic medicinetoxicologysystemdelaypetrol
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

A 12-year-old girl with severe cerebral palsy (quadriplegia) died from aspiration pneumonia whilst in state care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence,…

paediatricspalliative care
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
VICcommunity2014-04-07

Finding into death of Kirk Ardern

32y · Male·Multiple drug toxicity (including heroin)

…Ardern, a 32-year-old male with a long history of opioid dependence and substance abuse, died from multiple drug toxicity (including heroin) three days after release from prison. Two critical clinical failures contribute…

general practiceaddiction medicinemedicationcommunicationheroin
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 …

general practiceforensic medicinecommunicationsystemoxycodone
VIChome2023-10-12

Finding into death of Amanda Jane Harris

36y · Female·Stab wound to the right chest

…afaxine three days before the homicide, he developed acute psychosis likely related to tramadol withdrawal, drug interaction, or combination with recent substance cessation. He stabbed Ms Harris multiple times, set fire …

general practicepain medicinemedicationcommunicationtramadol
ACThome2019-06-04

Inquest into the death of Lauren Maree Johnstone

48y · Female·Combined toxic effect of prescription and non-prescription medications including…

…. Critical clinical lessons include: (1) obtaining complete medication histories including over-the-counter drugs, particularly sedating agents; (2) ensuring communication between treating specialists about concurrent me…

general practicesurgerycommunicationsystemdoxylamine
QLD2023-10-03

Findings of the inquest into the death of GLT

46y · Male·Methylamphetamine toxicity and coronary atherosclerosis

A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…

emergency medicineintensive carediagnosticdelaymethamphetamine
VIChome2024-05-24

Finding into death of L I

16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…

…ear-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescriptions from…

general practicepsychiatrymedicationdiagnosticcodeine
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
QLDhospital2005-08-24

Sabadina, Kathryn Marnie

28y · Female·Anaphylactic reaction to anaesthetic drug (suxamethonium), with underlying coron…

A 28-year-old woman died during routine dental extraction under general anaesthesia at a regional hospital. Despite competent initial airway management, she developed severe respiratory distress immediately after inducti…

anaesthesiadentistrydiagnosticproceduralpropofol
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

…ds, seek collateral information from family members, and integrate care across mental health and substance misuse.

general practicepsychiatrydiagnosticcommunicationcannabis
NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

…tal arrival. Systemic failures included poor prisoner access to opioid substitution therapy driving illicit drug use, ready availability of stockpiled paracetamol, and misunderstandings of transfer protocols.

emergency medicinetoxicologydiagnosticcommunicationparacetamol
VICcommunity2025-09-01

Finding into death of Ms FSZ

32y · Female·Compression of the neck

FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine

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