Coronial
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VICcommunity2019-10-30

Finding into death of Sanaya Sahib

1y · Female·Suffocation

…k. Ms Nikat was experiencing significant social isolation, family violence from her husband and in-laws, depression, parenting difficulties, and stress. Clinical lessons include the missed opportunity for repeat postnata…

obstetricspsychiatrysystemdelaymethamphetamine
VIChome2018-07-10

Finding into death of Shrihan Gannaram

<1y · Male·Multiple injuries sustained from impact with the ground from an extended height …

…ulting in multiple injuries including abdominal stab wounds. His mother, despite experiencing postpartum depression and social isolation (with only one friend in Australia), had no identified mental health issues at the …

paediatricsobstetricssystem
VIChome2021-02-25

Finding into death of Rosemary Gibson

62y · Female·Gunshot wounds to the head

…nce, with multiple risk factors present: the perpetrator had access to firearms, was unemployed, and had depression and frontotemporal dementia. The couple were experiencing relationship breakdown with financial stress, …

general practicepsychiatry
VIChospital2024-01-18

Finding into death of Lily Grace Arbuckle

<1y · Female·Head injury

… on train tracks during what was determined to be infanticide. The mother had severe untreated postnatal depression and anxiety, experiencing suicidal ideation and fixated concerns about harming her baby. Maternal and Ch…

obstetricspaediatricsdiagnosticcommunication
VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

…, Youth Justice, and the Adolescent Forensic Health Service. Despite psychiatric assessments identifying depression, anger issues, and trauma, psychiatrists recommended involuntary admission which was deemed impractical.…

psychiatrypsychologysystemdelay
NSWhome2023-08-15

Inquest into the death of LA

5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity

…A for extended periods despite hot weather and her recent minor illness; once opioid-induced respiratory depression and hypoxia developed, naloxone proved ineffective as significant brain damage had already occurred. Ear…

paediatricsintensive caredelaycommunicationmethadone
VICcommunity2024-04-23

Finding into death of Carolyn Mary James

3y · Female·Effects of fire deliberately set by mother in motor vehicle

…able evidence suggests possible misidentification of the dynamics. Ms Thomas had been assessed with mild depression by her GP but had not received formal mental health assessment despite concerning symptoms. The coroner …

general practicepsychiatrydiagnosticsystem
WAhome2013

Inquest into the Death of Stevens, Malachi Isaac and Stevens, Lochlan James

10y · Male·Unascertainable

Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…

paediatricsforensic medicinesystemdelay
VIChome2016-03-16

Finding into death of AA (Baby D)

<1y · Female·head injuries

…d injuries inflicted by her mother, a previously well-functioning woman suffering unrecognized postnatal depression during the stressful period of managing unsettled twins with colic and poor weight gain. The case reveal…

general practicepaediatricsdiagnosticcommunication
VIChome2025-03-12

Finding into death of H D

11y · Female·Pneumonia complicating cerebral palsy secondary to KCNQ2 developmental and epile…

…h severe cerebral palsy, epilepsy, and multiple complex medical conditions including central respiratory depression and recurrent chest infections. She died from pneumonia at home in August 2023 after a 12-month period o…

paediatricspalliative care
VIChome2021-06-29

Finding into death of HM

15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…

HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension.…

paediatricspsychiatrysystemdelaylovan
NSWhome2015-10-09

Inquest into the deaths of Geoffrey Francis Hunt, Kim Jeanine Hunt, Fletcher Austin Hunt, Mia Isobel Hunt, Phoebe Amelia

Male·Gunshot wound to the head

… personality, causing disinhibited anger and criticism; pre-existing marital tensions; Geoff's untreated depression and emotional dependency; and family business financial disputes. The coroner found the medical, mental …

psychiatrypsychologycitalopram
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

…e interventions (restraint, nasogastric feeding) require reassessment if escalating; comorbid autism and depression demand earlier formal diagnosis and coordinated treatment; and families need intensive in-home meal supp…

psychiatrypaediatricsdiagnosticsystemparacetamol
WAhospital2005-05-04

Inquest into the Death of Michael Anderson

<1y · Male·Sequelae of drug toxicity (poisoning) — specifically respiratory depression and …

…mg/L—approximately 40 times and 20 times therapeutic levels respectively. The codeine caused respiratory depression and brain damage; the paracetamol caused hepatotoxicity. The child died on 1 March 2001. The coroner fou…

neonatologypaediatricscommunicationdelayparacetamol
VIChome2023-07-27

Finding into death of Mr A

31y · Male·Hanging

…gular, systematic mental health risk assessment in community settings, particularly for individuals with depression, suicidal ideation history, and active substance misuse; (2) need for integrated information-sharing bet…

psychiatrygeneral practicesystemcommunicationmethamphetamine
VICcommunity2025-08-27

Finding into death of Conan James Smith

37y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…oroner found he intended to take his own life, and in doing so caused his son's death. Conan had treated depression and anxiety with mirtazapine, reported as effective at his last consultation in January 2024. He express…

psychiatrygeneral practicecommunicationdelaymirtazapine
NSWhospital2020-01-31

Inquest into the death of OS

5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …

…e with the child's existing sedative medications (clobazam, valproic acid, clonidine) led to respiratory depression and death. The death was potentially preventable through: specialist consultation on polypharmacy risks,…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
SAhome2000-03-08

Coroner's Finding: KAPTSIS Michael Vasilious

3y · Male·smothering

… his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequate. The child's mother had a six-year history…

psychiatryemergency medicinelithium carbonate
WAhome2021-04-16

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

3y · Female·tramadol toxicity

…. The Department's case management failed to escalate concerns about the carer's deteriorating capacity, depression, illicit drug use, and the children's poor school/daycare attendance. Geographic distance from the offic…

paediatricsforensic medicinesystemdelaytramadol
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

A 27-year-old carpenter with a long history of depression, suicidality, and substance abuse died by hanging. He had experienced recent family violence incidents a…

psychiatrygeneral practicecommunicationsystemvenlafaxine

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