Coronial

213 results for medication dependence

SAhome2002-05-23

Coroner's Finding: DAVIES Nicole Memory Faye

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…

general practiceaddiction medicinediagnosticmedicationmethadone
VIChospital2022-08-26

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain and opioid dependence, died from hypoxic ischaemic encephalopathy following mixed drug toxicity. She underwent a ketamine infu…

pain medicineaddiction medicinecommunicationsystemmethadone
SAprison2005-05-31

Coroner's Finding: McLEOD Ian

45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage

Ian McLeod, a 45-year-old lawyer with alcohol dependence and depression, died from hypoxic brain damage and bronchopneumonia following a hanging while in custody…

psychiatrycorrectional healthdiagnosticcommunicationdiazepam
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…

…ate care following removal from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence, presenting substance-affected whilst caring for her profoundly disabled daughter who required 24/7 supe…

paediatricspalliative care
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

…ual drug tolerance or heroin use; no inpatient management despite extreme complexity; and benzodiazepine dependence not registrable like opioid addiction. Real-time prescription monitoring systems could have alerted doct…

general practiceaddiction medicinediagnosticcommunicationalprazolam
VIChome2010-12-16

Finding into death of Melissa Deborah Irwin

35y · Female·methadone toxicity

…oner found the death accidental and identified critical system failures: unsecured storage of Schedule 8 medication in a domestic setting and lack of regulatory oversight of take-home dose safety. The coroner emphasised …

toxicologyaddiction medicinesystemcommunicationmethadone
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

… He had multiple comorbidities including congestive heart failure, COPD, and bipolar disorder, with poor medication compliance from 2018. He was non-compliant with care, refusing physical examination and vital sign check…

psychiatryemergency medicinecarbamazepine
TAScommunity2021-05-12

Coroner's Finding: Ghanbarzadeh, Masoud

51y · Male·blunt trauma of the chest sustained in a motor vehicle crash; hypovolemic shock …

…e coroner found these drugs significantly impaired his driving ability. His GP had authorised additional medication two days prior after the patient falsely claimed to be travelling. While the GP's prescribing was deemed…

general practicepsychiatrycommunicationdiazepam
VIChome2018-07-29

Finding into death of Diane Maria Hillgrove

34y · Female·Mixed drug toxicity

…acy pickups and prescription monitoring, she obtained pregabalin from multiple doctors and used diverted medications. On 6 July, Dr V. appropriately increased her pregabalin to 150mg for acute abdominal pain, but she lik…

general practicepsychiatrysystempregabalin
NSW2025-08-22

Inquest into the death of Michael Black

33y · Male·stab wound to the chest

…stabbed by fellow inmate Emmett Sheard in a crowded holding cell during a dispute over diverted Suboxone medication. Critical failures contributed to this death: (1) Sheard had been released from segregation prematurely …

correctional healthaddiction medicinediagnosticsystembuprenorphine
VIChome2025-03-18

Finding into death of R T

66y · Male·Complications of excess alcohol intake in a man with heart disease

A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic p…

general practiceemergency medicinealcohol
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

…ronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, antidepressants, and analgesics. The coroner identified that her GP prescrib…

general practicepsychiatrymedicationcommunicationflunitrazepam
VIC2016-02-26

Finding into death of Jonas Jvirblis

23y · Male·combined drug toxicity (oxymorphone, benzodiazepines, codeine, and morphine) in …

…ddiction medicine assessment recommending specialist management, he continued polysubstance use and self-medication. Critically, he gained unauthorised access to schedule 8 opiates from an adjoining laboratory at Monash …

psychiatryaddiction medicinesystemcommunicationoxymorphone
SAhospital2012-09-05

Coroner's Finding: KAY Damian

38y · Male·Multiple injuries

Damian Kay, aged 38, died from multiple injuries after jumping from the 16th floor of a hotel on 22 September 2010, with a blood alcohol concentration of 0.71%. The death occurred in the context of recent relationship br…

emergency medicinepsychiatrydiagnosticcommunicationvenlafaxine
VIC2013-06-05

Finding into death of Leigh Ronald Bellingham

37y · Male·Toxic effects of heroin in combination with mirtazapine and sertraline

…ts of heroin in combination with mirtazapine and sertraline in June 2008. He was prescribed psychotropic medications and benzodiazepines by his GP despite being a documented suicide risk. Large quantities of medications …

general practicepsychiatrycommunicationsystemheroin
NSW2017-11-06

Inquest into the death of Edward Haenga

37y · Male·cardiac arrhythmia

…37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) pol…

psychiatrygeneral practicemedicationproceduralescitalopram
VIC2012-09-21

Finding into death of Timothy Casey

41y · Male·Hanging

…imothy Casey, a 41-year-old remand prisoner with a history of major depressive disorder and drug/alcohol dependence, died by hanging in Port Phillip Prison in March 2008. The coroner identified multiple system failures: …

psychiatrycorrectional healthdiagnosticcommunication
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

51y · Female·Cannot be determined; likely mixed drug (including alcohol) toxicity or undeterm…

…tory authorities are maintained when prescribing Schedule 8 substances; and (5) recognising that storing medications in shared households poses risks, particularly with vulnerable patients. While Dr P. had regulatory bre…

general practicepsychiatrymedicationsystemoxycodone
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

…ug-induced psychosis in November 2019. After discharge, despite mental health support and anti-psychotic medication, his mental state deteriorated with increased paranoia, substance use, and suicidal ideation. On the nig…

rheumatologyallergy and immunologycommunicationsystemoxycodone
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

…g present (recent separation, depression, sleep disorder, previous suicide attempt, isolation, financial dependence). The coroner found that standardised family violence screening using appropriate frameworks could have …

general practicepsychiatrydiagnosticcommunicationmorphine
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