304 results
27y · Female·Injuries sustained in motor vehicle incident (pedestrian)
Sophie Nicholas, aged 27, died by suicide after being struck by a truck while walking along a road at 1:30am on 15 September 2016. She had longstanding borderline personality disorder (BPD) and alcohol dependency, with f…
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
19y · Female·Stab wounds to the abdomen
Ms Abuk Derder Akek, a 19-year-old South Sudanese refugee, was fatally stabbed by her former de facto partner Makeny Banek during a violent assault at her home in Melton, Victoria on 13 March 2016. The finding identifies…
45y · Male·gunshot wound to the neck
Matthew Rosewarne, a 45-year-old man with chronic alcohol use disorder and recent relationship breakdown, was found dead in his shed with a gunshot wound to the neck. Although initially investigated as suicide, the coron…
Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …
Baby W was born at 37+5 weeks in an ambulance and died at Bendigo Hospital from intrauterine pneumonia and meconium aspiration secondary to intrauterine growth restriction related to maternal amphetamine use. The mother …
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received buprenorphine for opioid withdrawal management alo…
24y · Male·Combined drug toxicity (heroin, benzodiazepine and others)
Samuel Morrison, 24, died from combined drug toxicity involving heroin, benzodiazepines and other substances. He had a long history of depression, anxiety and illicit drug use, and had recently been discharged from psych…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
26y · Female·Multiple drug toxicity
Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …
35y · Male·Neck trauma from hanging
Andrew John Jarman, a 35-year-old man with a significant history of depression, anxiety, alcohol and substance abuse, died by suicide in August 2012, though his remains were not discovered until October 2016 in Warrawee …
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
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…
30y · Male·acute alcohol (ethanol) toxicity
A 30-year-old male with severe alcohol dependence died from acute ethanol toxicity after a prolonged drinking episode. Despite engagement with alcohol and drug services, counselling, and family support, he was unable to …
54y · Male·Heroin overdose
A 54-year-old man with schizophrenia and long-standing substance use disorder died from heroin overdose in a squatter house in Collingwood. He had been discharged from psychiatric hospital six weeks prior on depot antips…
31y · Male·carbon monoxide toxicity
Shaun Martin Keane, aged 31, died by carbon monoxide toxicity while on home detention bail following arrest for assault. He had a documented history of suicidal ideation, including a previous gassing attempt in 2010, and…
36y · Female·Mixed drug toxicity
Skye Turner, a 36-year-old woman with borderline personality disorder and substance use disorder, died from mixed drug toxicity after being discharged from Maroondah Hospital on 8 March 2017. She had been admitted with o…
47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)
Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., starting April 2…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…
27y · Male·Mixed drug toxicity
A 27-year-old man with polysubstance abuse disorder, generalised anxiety disorder, and borderline personality disorder died from mixed drug toxicity (heroin, morphine, diazepam, citalopram, quetiapine) shortly after disc…
22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree
22-year-old Benjamin Gilligan died in a motor vehicle crash while fleeing psychiatric care, having been recently diagnosed with methylamphetamine-induced psychosis. Key clinical issues identified: (1) communication break…
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