Coronial

138 results for drug abuse (cannabis)

TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

…ice must be reinforced with at-risk families; multidisciplinary safeguarding must be robust when substance abuse and previous child injuries are known; systems failures can render clinical care irrelevant when children …

paediatricsforensic medicinesystemdelaymorphine
SA2013-02-14

Coroner's Finding: ROBINSON Shane Andrew

32y · Male·Gunshot wound to head (self-inflicted)

…a 32-year-old registered child sex offender and parolee with a long violent criminal history and substance abuse problems, died by self-inflicted gunshot wound while evading police during a siege at a rural property. He…

communicationsystemcannabis
ACT2018-04-11

AN INQUEST INTO THE DEATH OF STEVEN CLAUDE FREEMAN

25y · Male·Aspiration pneumonia secondary to methadone toxicity

Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…

addiction medicinegeneral practicediagnosticsystemmethadone
NSWaged care2020-07-29

Inquest into the death of John Pocklington

31y · Male·Acute Myocardial Infarction

John Pocklington, aged 31, died of acute myocardial infarction while in remand custody. He had a long history of methamphetamine use and untreated cardiac damage. On 28 April 2015, he reported chest pain to a nurse, who …

cardiologypsychiatrydiagnosticcommunicationmethamphetamine
WAhome2021-04-16

Inquest into the Death of Child LDW (Name Subject to Suppression Order)

3y · Female·tramadol toxicity

…nsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance abuse and placed with her step-father. Although police investigation concluded no deliberate harm, the death was…

paediatricsforensic medicinesystemdelaytramadol
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…

correctional healthgeneral practicediagnosticcommunicationmethadone
NSWcommunity2025-09-24

Inquest into the death of Matthew Richard Lothian

37y · Male·self-inflicted gunshot wound to the head and neck

…from Correctional Services Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predicament. The coroner i…

psychiatrycorrectional healthsystemcommunicationmethadone
QLD2025-10-08

Inquest into the death of Peter Owen Pilkington

48y · Male·gunshot wound to chest

Peter Owen Pilkington, 48, died from a gunshot wound sustained during a police siege on 6 December 2021. After escalating behaviour at his NDIS support office in Stretton, Queensland, Peter produced what police believed …

emergency medicinetrauma surgerysystemmethamphetamine
NT2025

Inquest into the death of Kumanjayi Walker

19y · Male·gunshot wounds to chest and abdomen

…Aboriginal communities. Key clinical/public health lessons include: inadequate mental health and substance abuse services contributed to vulnerabilities; failures in early intervention for young people with developmenta…

public healthpsychiatrycommunicationsystem
NSWhome2023-04-14

Inquest into the death of Stanley Leonard RUSSELL

45y · Male·gunshot wound to the chest with associated significant blood loss

…d by NSW police executing a bench warrant at his home on 9 November 2021. He had suffered childhood sexual abuse, his brother died by suicide in custody, and he feared incarceration due to prior self-harm episodes. Poli…

forensic medicineemergency medicinediagnosticcommunicationmethamphetamine
WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
WApolice custody2017-03-31

Inquest into the Death of Maureen MANDIJARRA

44y · Female·unascertained (consistent with Streptococcus dysgalactiae and Staphylococcus aur…

Maureen Mandijarra, a 44-year-old Aboriginal woman with poorly controlled diabetes and recurrent skin infections, was arrested at Male Oval on 29 November 2012 for street drinking under a zero-tolerance police approach. …

emergency medicineinfectious diseasesdiagnosticcommunicationalcohol
NTcommunity2022-05-20

Inquest into the death of Reginald Roy

16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis

Reginald, a 16-year-old Aboriginal boy with first episode psychosis, intellectual disability, and fetal alcohol spectrum disorder, was admitted to the Youth Inpatient Unit and improved significantly with inpatient care. …

psychiatrypaediatricscommunicationsystemaripiprazole
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
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding as…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
VIC2023-12-01

Finding into death of J ZA

17y · Female·Gamma hydroxybutyrate (GHB) toxicity

JZA, a 17-year-old in residential out-of-home care, died from GHB toxicity after returning to her residential unit intoxicated in the early morning. She was monitored by residential support workers throughout the day but…

communicationsystemgamma-hydroxybutyrate
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
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…

psychiatryemergency medicinecommunicationdiagnosticantidepressants

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