1,291 results
29y · Male·inhalation of petrol (hydrocarbon inhalation) causing respiratory depression wit…
Three Aboriginal men aged 25-29 years died from petrol inhalation in identical circumstances over 1999-2001, each found face-down in bed with a shaped petrol can sealed to their face. All were chronic sniffers (>10 years…
Female·Dothiepin toxicity
Yvonne Carrigg, a woman with recurrent post-natal depression, died from dothiepin overdose three days after psychiatric discharge. Critical clinical failures included: prescribing dothiepin (a cardiotoxic tricyclic antid…
34y · Female·Dothiepin toxicity in a setting of post-natal depression
Debra Smeeton, 34, died on 12 November 1999 from dothiepin toxicity following intentional overdose at home, eight days after giving birth. She had severe post-natal depression after her first child in 1996, requiring hos…
33y · Female·Immersion (drowning) by suicide
Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severely traumatic childhood characterised by emotional neglect,…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
22y · Male·Hypoxic Ischaemic Encephalopathy due to suffocation
Bradley William Rapley, aged 22, died from hypoxic ischaemic encephalopathy on 2 September 1999 at Fremantle Hospital after a suicide attempt by suffocation in a Casuarina Prison cell on 25 August 1999. Rapley was a pris…
38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…
A 38-year-old woman with long-standing heroin and benzodiazepine dependence died from mixed drug toxicity following injection of heroin. Her GP had prescribed multiple benzodiazepines (diazepam, oxazepam, temazepam) and …
17y · Female·mixed drug toxicity
Nicole Davies, 17, died from mixed drug toxicity after rapid methadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet receiv…
17y · Female·mixed drug toxicity
Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…
34y · Male·neck compression due to hanging
A 34-year-old man with longstanding psychiatric illness died by hanging four days after discharge from psychiatric hospital. He had been admitted twice in August-September 1999 with active suicidal ideation and homicidal…
47y · Male·neck compression due to hanging
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…
24y · Male·Aspiration of vomit associated with combined drug effect
Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…
18y · Male·Ligature Compression of Neck (Hanging)
Adam Timothy Garner, aged 18½, died by hanging in his prison cell at Canning Vale Prison Complex on 6 January 2000, approximately 24 hours after admission. He was on remand for a serious violent offence and was experienc…
35y · Male·neck compression from hanging
A 35-year-old man with a history of depression, substance abuse, and acquired brain injury from assault was admitted to a psychiatric ward after self-harm with suicidal ideation. He was detained under the Mental Health A…
25y · Male·coronary thrombosis resulting from coronary atherosclerosis
A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
29y · Female·asphyxiation due to ligature compression of the neck (hanging)
Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
22y · Male·Ligature Compression of the Neck (Hanging)
Dean Kieran Lauder, aged 22, died on 31 May 1998 at Canning Vale Prison by ligature strangulation (hanging) while in a punishment cell. He was serving a 7-day sentence for cannabis possession offences. He had a history o…
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