Coronial

173 results for cannabis abuse disorder

VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

…ging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked to petrol sniffing (chronic substance abuse causing severe neurological damage), mental health issues, and systemic service failures. Key clinical les…

psychiatryemergency medicinesystemdelaypetrol
NSW2022-10-12

Inquest into the death of ZH

29y · Male·Hanging

ZH, a 29-year-old man serving a 9-year sentence for drug supply, died by hanging in his minimum-security cell at Parklea Correctional Centre on 11 August 2021. The coroner found his death was self-inflicted. Key clinical…

psychiatrygeneral practicecommunicationsystemmethamphetamine
NTcommunity2022-05-20

Inquest into the death of Reginald Roy

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

…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. After discharge…

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
NSWcommunity2026-05-19

Inquest into the death of Dion White-Cotterell

45y · Male·Multiple stab wounds

… in Parramatta. Moore, suffering acute schizophrenia relapse with a long history of violence and substance abuse, was under Community Treatment Order supervision through Parramatta Community Mental Health Centre. The in…

psychiatrysystemcommunication
VIChospital2025-01-10

Finding into death of William Thomas Gourley

39y · Male·Effects of fire (self-immolation)

… 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 2022 with suicidal id…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
QLD2011-10-20

Hornby, Grace Ann; Hornby, Jessica Lee; Mansell, Denise Ann; Thomson, Anthony Paul

Unknown·Multiple injuries from motor vehicle accident; Anthony Paul Thomson died from ru…

Motor vehicle accident involving 4 deaths on 8 May 2009 at Nambour Connection Road and Blackall Street intersection, Queensland: 5-year-old twins, a 60-year-old female driver, and 43-year-old male driver Anthony Paul Tho…

general practicepsychiatrysystemcommunicationdextroamphetamine
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
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
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

A nine-month-old First Nations child (Baby Q) was killed by her psychotic father in November 2018. The family, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental h…

paediatricspsychiatrysystemcommunication
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
NSW2022-08-26

Inquest into the death of LAK

19y · Male·Hanging

LAK, a 19-year-old Aboriginal man, died by suicide at a community rehabilitation facility after a complex mental health journey involving forensic orders and psychosis. Key clinical lessons include: recognising vulnerabi…

psychiatryaddiction medicinecommunicationsystem
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

…n, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose attempts. Key clinical lessons include: the failure to maintain continui…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
VIChospital2023-05-16

Finding into death of Mathew James Luttrell

43y · Male·Hanging

Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide…

psychiatryemergency medicinecommunicationdelayolanzapine
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
TASprison2024-04-18

Coroner's Finding: Gerard, Robert Harold

48y · Male·Hanging (partially suspended hanging using shoelaces as ligature)

…n May 2022 while on remand for serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depression and suicidal ideation. The coroner found his mental health care was reaso…

psychiatrycorrectional healthsystemdelayzuclopenthixol decanoate
SA2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…

This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…

psychiatryemergency medicinecommunicationsystempetrol
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol
VICmental health2012-10-12

Finding into death of Grant Elliot Phillips

29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)

Grant Phillips, 29-year-old with schizophrenia and complex psychiatric history including multiple suicide attempts, was admitted involuntarily to Broadmeadows Inpatient Psychiatric Unit on 5 May 2007. Despite being asses…

psychiatrydiagnosticsystemdextroamphetamine
1789

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