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SA2019-11-14

Coroner's Finding: SINGH Heidi Eileen Roseanne

14y · Female·electrocution

Heidi Singh was a 14-year-old Aboriginal girl who died by electrocution at a railway pylon on 21 August 2014. She had suffered from foetal alcohol spectrum disorder since early childhood, experienced multiple losses (par…

paediatricspsychiatrysystemcommunicationquetiapine
WA2019-11-13

Inquest into the Death of Bret Lindsay CAPPER

43y · Male·bronchopneumonia and brain swelling following ligature compression of the neck (…

Bret Lindsay Capper, 43-year-old male remanded in custody at Hakea Prison, Western Australia, died on 14 January 2016 from bronchopneumonia and brain swelling following ligature asphyxiation by hanging. He had antisocial…

psychiatrypsychologysystemcommunicationheroin
VIChospital2019-11-11

Finding into death of Hilda Joan Berg

89y · Female·Aspiration pneumonia complicating electroconvulsive therapy for treatment of psy…

Hilda Berg, 89-year-old woman with depression, psychosis, atrial fibrillation, chronic kidney disease and type 2 diabetes, deteriorated in hospital with refusal to eat or drink due to psychotic beliefs. After initial con…

psychiatrygeriatric medicinecommunicationsystemolanzapine
NSW2019-11-08

Inquest into the death of six patrons of NSW music festivals

Unknown·MDMA toxicity (3,4-methylenedioxymethylamphetamine toxicity) in each case

Six young people died at NSW music festivals between December 2017 and January 2019 after consuming MDMA (ecstasy) at toxic levels. Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), Joshua Tam (…

emergency medicinetoxicologycommunicationsystemMDMA
WAcommunity2019-11-07

Inquest into the Death of Brendan John LINDSAY

38y · Male·Multiple gunshot wounds

Brendan John Lindsay, 38, died from multiple gunshot wounds inflicted by four police officers responding to a hostage situation in Carlisle, WA. Lindsay, intoxicated with methamphetamine and displaying erratic behaviour,…

psychiatryemergency medicinemethamphetamine
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…

psychiatryneurologydiagnosticcommunicationolanzapine
VICcommunity2019-10-30

Finding into death of Sanaya Sahib

1y · Female·Suffocation

Sanaya Sahib, age 14 months, died from suffocation on 9 April 2016. Her mother, Sofina Nikat, deliberately suffocated her and left her body in Darebin Creek. Ms Nikat was experiencing significant social isolation, family…

obstetricspsychiatrysystemdelaymethamphetamine
SAhospital2019-10-29

Coroner's Finding: PEMBERTON Graham Ashton

87y · Male·aspiration pneumonia, urinary tract infection and general inanition complicating…

Graham Pemberton, 87 years old with advanced Alzheimer's dementia, died of aspiration pneumonia, urinary tract infection, and general inanition. He was admitted to hospital multiple times in 2015 with behavioural disturb…

geriatric medicinepsychiatry
SAhome2019-10-29

Coroner's Finding: LATTUCA Christophe Thomas Bruno

34y · Male·neck compression due to hanging

A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services staff. In the 24 hours befor…

general practicepsychiatryalcohol
VIChospital2019-10-29

Finding into death of Ms C

49y · Female·hypoxic ischaemic encephalopathy complicating cardiac arrest due to pulmonary th…

A 49-year-old woman with morbid obesity, obstructive sleep apnoea, and psychiatric history was admitted following deliberate medication overdose. She was intubated, managed in ICU, then transferred to the ward where she …

emergency medicineintensive caresystemheparin
VICmental health2019-10-29

Finding into death of Elizabeth Honor Ewart

55y · Female·Unascertained

Elizabeth Ewart, aged 55, died at The Melbourne Clinic on 27 February 2017. She had bipolar disorder, anxiety and schizoaffective disorder. After administering PRN Olanzapine 2.5mg at 4:35pm for agitation, Nurse Cook was…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWmental health2019-10-25

Inquest into the death of T V

23y · Female·Arrhythmia of unknown aetiology

TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…

psychiatrycardiologyhaloperidol
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem
SAcommunity, workplace2019-10-23

Coroner's Finding: Murray, Erin Paige and Patterson, Amy Jean

Female·pentobarbitone toxicity

Two veterinary-associated women (a veterinary student and a practicing veterinarian) died from pentobarbitone toxicity via ingestion, with evidence of intentional self-harm. The coroner identified that both women had acc…

veterinary medicinepsychiatrysystemdelaypentobarbitone
VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

A 24-year-old man died from mixed drug toxicity after staying overnight at a backpackers hostel. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including …

psychiatrygeneral practicecommunicationsystempregabalin
NSWhome2019-10-18

Inquest into the death of Aron MYERS

45y · Male·cardiac arrhythmia whilst being restrained, in the context of methamphetamine as…

Aaron Myers, 45, died from cardiac arrhythmia during a family altercation whilst being physically restrained. He had pre-existing methamphetamine-associated cardiomyopathy, hypertensive heart disease, and chronic emphyse…

psychiatrycardiologymethamphetamine
TAShome2019-10-16

Coroner's Finding: Powell, Stephen Maxwell

72y · Male·exsanguination (blood loss) from severed femoral artery

Stephen Maxwell Powell, a 72-year-old man with schizophrenia, died by exsanguination from a self-inflicted femoral artery laceration. He was discharged from psychiatric inpatient care on a community treatment order on 14…

psychiatrygeneral practicehaloperidol decanoate
VICaged care2019-10-15

Finding into death of Patricia O'Connor

84y · Female·Multisystem organ failure related to complications from a fall resulting in hip …

Patricia O'Connor, 84-year-old woman with bipolar disorder, was admitted involuntarily to Sunshine Aged Persons Mental Health Unit on 15 August 2017 during a manic relapse. On 25 August, she fell and fractured her right …

psychiatrygeriatric medicinesystempaliperidone
ACTcommunity2019-10-14

Inquest into the death of Adrian Pitman

54y · Male·Multiple injuries due to motor vehicle collision with retaining wall caused by d…

Adrian Pitman, a 54-year-old man with treatment-resistant schizophrenia, died by suicide following a motor vehicle collision with a retaining wall. He was subject to a psychiatric treatment order and had 33 different cas…

psychiatrycommunicationsystemolanzapine
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone

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