Coronial
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TAShome2026-03-23

Coroner's Finding: de-identified ZA

51y · Female·Unintentional prescription drug poisoning due to central nervous system depressi…

A 51-year-old woman with chronic pain, depression, and longstanding medication misuse died from unintentional prescription drug poisoning. She had been pr…

general practicepain medicineoxycodone
VIChome2025-08-07

Finding into death of Emma Louise Terrill

41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity

…evated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergistic CNS depression. Evidence suggests Emma consumed significantly more tramadol than prescribed (up to 850mg versus 450-500…

general practicepsychiatrysystemtramadol
VIChome2010-05-06

Finding into death of Simon Mark Gray

31y · Male·Combined effects of multiple drugs in an obese male with findings suggestive of …

…ere workplace back injury (lumbar disc prolapse and compression) in March 2006, leading to chronic pain, depression, and anxiety. Multiple treatment interventions—including pain management and rehabilitation—failed to re…

general practicepsychiatrydelaysystemmorphine
TAShome2017-12-07

Coroner's Finding: Simpson, Peter Lawrence

61y · Male·mixed prescription drug toxicity (methadone, diazepam, promethazine) with aspira…

…ng medications without food. The coroner found therapeutic drug levels but noted synergistic respiratory depression from the drug combination, combined with CNS depression from alcohol, led to airway compromise and aspir…

general practicepain medicinesystemmethadone
NSWhome2017-03-07

Inquest into the death of Louis NAUMOVSKI

59y · Male·Unascertained

Louis Naumovski, a 59-year-old man with a long history of substance use disorder, chronic pain, depression, and multiple suicide attempts, was found deceased at his home after approximately three weeks. The exac…

addiction medicinepain medicinefentanyl
TAShome2022-11-28

Coroner's Finding: Dare, Daniel Wayne

Male·mixed prescription drug toxicity (tramadol and diazepam)

…scription drug toxicity involving tramadol and diazepam. He had a history of chronic lower back pain and depression managed with these medications prescribed by his GP over several years. While he had previous suicide at…

general practicepsychiatrytramadol
TAShome2015-03-20

Coroner's Finding: Balmer, Rosemary Joy

50y · Female·Mixed prescription drug toxicity (oxycodone, amitriptyline, diazepam, diphenhydr…

…e coroner found no suspicious circumstances and concluded the death resulted from central nervous system depression leading to respiratory arrest. Key clinical lessons include the complexity of managing chronic pain with…

general practicepain medicinesystemoxycodone
VIChospital2021-05-01

Finding into death of Sharni Dee Connolly

37y · Female·Multiple drug toxicity

…creasing confusion and dazed appearance. On 20 October 2018, she was found unresponsive with respiratory depression, suffered hypoxic brain injury despite resuscitation, and was declared brain dead. The Coroner's Prevent…

general practiceemergency medicinemedicationcommunicationtapentadol
SAhome2010-06-04

Coroner's Finding: ARBUCKLE Claudia Anna Maria

44y · Female·mixed drug toxicity with aspiration of gastric contents

A 44-year-old woman with chronic back pain and depression died from mixed drug toxicity with aspiration of gastric contents. She had been prescribed multiple medi…

general practicepain medicineamitriptyline
TAShome2018-03-19

Coroner's Finding: MC

22y · Male·combined mixed drug intoxication

A 22-year-old medical student with chronic spinal cord pain and depression died from combined drug intoxication involving U-47700 (a potent uncontrolled synthetic opioid 7.5 times…

general practicepsychiatrysystemu-47700
WAcommunity2020-10-02

Inquest into the Suspected Death of Jorn Jesper JENSEN

68y · Male·unascertained

…ic medical conditions including peripheral neuropathy, chronic pain, atrial fibrillation, dysphagia, and depression disappeared on 25 June 2017. He left home, drove his car to Lancelin Beach (130 km away), and was never …

general practicecardiologybuprenorphine
TAShome2025-12-11

Coroner's Finding: de-identified SH

57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…

…ity. She had severe chronic pain following abdominal surgeries, opioid addiction managed with methadone, depression, and multiple psychiatric conditions. On the evening of her death, she consumed alcohol while taking pre…

general practicepharmacologymedicationmethadone
QLDhome2016-08-26

Winbank, Leslie Geoffrey

53y · Male·Self-inflicted gunshot wound to the head

…lude recognising suicide risk in patients with multiple stressors (chronic pain, relationship breakdown, depression history), ensuring accessible mental health support during crisis, and monitoring medication compliance …

psychiatrypain medicineoxycodone
SAhospital2018-10-10

Coroner's Finding: ATKINS Stephen Robert

53y · Male·fentanyl and oxycodone toxicity

…nformation; failure to recognise clinical deterioration despite clear family observations of respiratory depression and profound drowsiness; and prescription of slow-release oxycodone (OxyContin) in combination with fast…

neurologyemergency medicinediagnosticmedicationfentanyl
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multi…

general practicepsychiatrymedicationcommunicationflunitrazepam
ACThome2018-06-25

INQUEST INTO THE DEATH OF SUELLEN EDITH DAVIS

57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…

…ounter without medical knowledge. These sedating drugs combined caused severe drowsiness and respiratory depression, preventing her from extricating herself from a flexed-neck position against a coffee table. Contributin…

general practicepain medicinecommunicationsystemoxycodone
TAShome2022-10-25

Coroner's Finding: Meyer, Glenn Sturley

45y · Male·mixed drug toxicity

…lenn Sturley Meyer, aged 45, died from mixed drug toxicity on 22 August 2019. He had chronic pain, PTSD, depression and anxiety managed with oxycodone and diazepam. He also had obesity and probable obstructive sleep apno…

general practicepsychiatryoxycodone
VICcommunity2010-01-14

Finding into death of Joeanne Maree Brady

39y · Female·Mixed drug toxicity (methadone, oxycodone, hydromorphone, mirtazapine, diazepam,…

…ntinued taking oxycontin while starting methadone, resulting in combined opioid toxicity and respiratory depression leading to death four days later. Key failures: inadequate explanation of medication change, no written …

pain medicineneurologycommunicationmedicationmethadone
VIChome2015-11-16

Finding into death of Leanne Margaret Patterson

52y · Female·gunshot wound to head

…nclude: GPs should maintain a low threshold for asking about family violence in patients presenting with depression, chronic pain, insomnia and social isolation, even if they lack obvious indicators; better coordination …

general practicepain medicinecommunicationsystemclonazepam
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

A 52-year-old man with multiple sclerosis, chronic pain, depression and history of suicidality died from mixed drug toxicity following an intentional overdose. He was presc…

general practiceneurologymedicationcommunicationfentanyl

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