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VIChome2019-08-21

Finding into death of Leslie Hawkins

57y · Male·Complications of opioid (hydromorphone and morphine) toxicity and incised wounds…

Leslie Hawkins, aged 57 with dementia and significant medical comorbidities, died from opioid toxicity and incised wrist wounds as part of a suicide pact with his terminally ill wife. Mrs Hawkins, diagnosed with advanced…

geriatric medicinepalliative carehydromorphone
VIChome2019-08-15

Finding into death of Jovan Kozarov

62y · Male·Incised wound to the neck

A 62-year-old man died from an incised neck wound inflicted by his son during a psychotic relapse. The son, with a 15-year history of schizophrenia managed in the community, was experiencing worsening psychotic symptoms …

psychiatryforensic medicinecommunicationsystem
SAhome2019-08-14

Coroner's Finding: KUSKOFF Alexander Peter

50y · Male·gunshot wounds to chest and abdomen

Alexander Kuskoff, aged 50, was fatally shot by STAR Group officer DA on 16 September 2015 following a mental health crisis. Kuskoff displayed florid psychotic symptoms including paranoid delusions, was heavily armed, an…

psychiatryemergency medicinecommunicationsystem
TAScommunity2019-08-13

Coroner's Finding: Jeffrey, Angela Joy

53y · Female·Unable to determine; circumstances suggest death by suicide but body never recov…

Angela Joy Jeffrey, a 53-year-old woman with a long history of depression managed with antidepressants and psychiatric care, disappeared on 1 June 2016 from Bakers Beach, Tasmania. She had experienced a significant mood …

psychiatrygeneral practiceantidepressant medication
VIChome2019-08-12

Finding into death of Traci O'Sullivan

42y · Female·The combined effects of blunt force injuries to the head and penetrating injurie…

Traci O'Sullivan, 42-year-old woman, died from combined blunt force injuries to the head and penetrating injuries to the neck, chest and abdomen. The death occurred between 5-7 February 2015 at her home in Frankston Nort…

psychiatrytoxicologymethamphetamine
VIChome2019-08-06

Finding into death of Angelina Alviano

67y · Female·Sudden unexpected death in epilepsy in a woman with schizophrenia and cardiomega…

A 67-year-old woman with epilepsy, schizophrenia, and cardiomegaly died suddenly and unexpectedly at home in disability accommodation. The coroner determined the cause as sudden unexpected death in epilepsy (SUDEP). The …

neurologypsychiatrylamotrigine
NSWcommunity2019-08-05

Mokmool

30y · Male·gunshot wound to the head as a result of a police operation

Danukul Mokmool, aged 30, died on 26 July 2017 after being shot by NSW Police at Central Railway Station following a mental health crisis. He was experiencing acute psychosis with paranoid delusions that his family inten…

psychiatrygeneral practicemethadone
WAhospital2019-08-02

Inquest into the Death of Timothy James CHANDLER

52y · Male·multiple organ failure and pulmonary thromboemboli complicating generalised seps…

A 52-year-old man with longstanding refusal of medical care presented with severe cellulitis, sepsis, and previously undiagnosed heart failure secondary to sleep apnoea. He lacked capacity to consent to treatment due to …

emergency medicinegeneral medicine
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…

psychiatrygeneral practicediagnosticcommunicationhydromorphone
WAcommunity2019-08-01

Inquest into the Death of Matthew James BALE

38y · Male·Unascertained; death in the waters of the Indian Ocean off Rottnest Island

Matthew James Bale, a 38-year-old man, disappeared from Rottnest Island on 21 March 2016 while on holiday with his wife and parents. He had a history of depression, alcohol and drug addiction, and recent drug-induced psy…

psychiatryaddiction medicinecitalopram
VICcommunity2019-07-30

Finding into death of Caterina Fratto

45y · Female·Hanging

A 45-year-old woman with bipolar affective disorder, borderline personality disorder, anorexia nervosa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health…

psychiatrygeneral practicecommunicationdocumentationquetiapine
VIChospital2019-07-30

Finding into death of Allison Judith Allan

43y · Female·Hypoxic ischaemic brain injury resulting from alcohol and sodium valproate toxic…

43-year-old woman with epilepsy and depression died from hypoxic ischaemic brain injury after ingesting 15g sodium valproate and 750ml vodka. Critical failures occurred across multiple settings: VPIC provided incomplete …

emergency medicineintensive carediagnosticcommunicationsodium valproate
VICaged care2019-07-30

Finding into death of James Cowl

68y · Male·Cardiomegaly

James Kenneth Cowl, a 68-year-old man with severe cardiomyopathy, atrial fibrillation, schizophrenia, and intellectual disability, died suddenly from cardiomegaly while in residential care. An echocardiogram performed sh…

cardiologygeneral practicebisoprolol
NSWcommunity2019-07-30

Inquest into the death of Dennis Brooks

35y · Male·Unknown

Dennis Brooks, 35, a man with paranoid schizophrenia, disappeared from his Katoomba home on 2 May 2016 after exhibiting signs of psychotic relapse. Although his sister reported him missing on 4 May, a coordinated land se…

psychiatryforensic medicinecommunicationsystem
SAhome2019-07-24

Coroner's Finding: McNAMARA-CUTLER Juanita Lee

26y · Female·neck compression due to hanging

Juanita Lee McNamara-Cutler, a 26-year-old mother of three with a complex history of mental illness, substance abuse, and prior suicide attempts, died by hanging on 7 September 2014, three days after release on home dete…

psychiatryforensic medicinemethamphetamine
WAcommunity2019-07-23

Inquest into the Death of Andrew Michael WATSON

46y · Male·immersion in the Indian Ocean

Andrew Michael Watson, a 46-year-old elevator technician, disappeared on 11 May 2013 after leaving a nightclub in Northbridge, Perth. His car was found at a dog beach carpark near the ocean. Notes in his car indicated su…

psychiatryemergency medicinesystem
WAhome2019-07-23

Inquest into the Death of Stephen Thomas OXLEY

52y · Male·atherosclerotic and hypertensive heart disease

Stephen Thomas Oxley, a 52-year-old man with schizoaffective disorder managed on a Community Treatment Order, died of atherosclerotic and hypertensive heart disease. He had multiple modifiable cardiovascular risk factors…

psychiatrygeneral practiceflupenthixol
VIChome2019-07-18

Finding into death of Christopher George

28y · Male·Gunshot wound to the head

Christopher George, a 28-year-old man with a history of depression and suicidal ideation, died from a self-inflicted gunshot wound while police conducted a welfare check at his home. He had stopped taking sertraline (ant…

psychiatrygeneral practicesystemsertraline
WAcommunity2019-07-17

Inquest into the Death of Mark Quenton FLEURY

38y · Male·ligature compression of the neck (hanging)

Mark Quenton Fleury, a 38-year-old man with paranoid schizophrenia, died by suicide on 14 February 2016 while subject to a Community Treatment Order. In the final week of his life, he presented to emergency services and …

psychiatryemergency medicinecommunicationsystemrisperidone
VIC2019-07-17

Finding into death of Fiona Warzywoda

33y · Female·Stab wounds to the chest (tension hemopneumothorax resulting from stab wounds)

A 33-year-old woman was fatally stabbed by her separated de facto partner following a 18-year relationship marked by escalating family violence. Multiple agencies had contact with the victim in the weeks before her death…

paediatricspsychiatrydiagnosticcommunication

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