Coronial

32 results for drug-induced respiratory depression

TASaged care2015-11-12

Coroner's Finding: Henri, Paul Lucien

78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…

… observations despite new sedating medications. Combination morphine with quetiapine likely exacerbated respiratory depression. The patient rapidly deteriorated with hypoxia, hypotension, and altered consciousness. Whil…

general practiceneurologymedicationdiagnosticmorphine
WAhospital2005-09

Inquest into the Death of Vicki Anne Greaves

36y · Female·Pneumonia complicating combined drug effect

…ined heroin and, in combination with prescription medications (dexamphetamine and temazepam), developed respiratory depression and aspiration pneumonia. The coroner found she had manipulated multiple systems—Department …

addiction medicinepsychiatrycommunicationsystemheroin
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

… therapeutic doses, suggesting possible overdose; (2) sleep observations documentation failed to record respiratory status as required by policy; (3) cardiac monitoring protocols were actually exceeded standards; (4) th…

psychiatrycardiologycommunicationsystemclozapine
TAShome2018-01-29

Coroner's Finding: Stewart, Justin Blade

36y · Male·mixed drug toxicity

…is detected. All medications are CNS depressants; their concomitant use increases the risk of severe CNS depression, respiratory depression, and death. The coroner accepted that death resulted from this drug combination …

psychiatrygeneral practicequetiapine
SA2001-10-05

Coroner's Finding: GEAR David Richmond

34y · Male·Mixed methadone and thioridazine toxicity

…thadone maintenance (110mg daily) for opioid addiction and was prescribed thioridazine 100mg nightly for depression. Post-mortem toxicology showed toxic methadone levels (1.9mg/L) and therapeutic thioridazine despite sta…

psychiatrygeneral practicemethadone
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
WAhome2012-09-07

Inquest into the Death of Mulvaney

54y · Female·Multi-organ failure following a decreased level of consciousness caused by compl…

Linda Christina Mulvaney, 54, died of multi-organ failure following a prolonged period of unconsciousness caused by a combination of obstructive and central sleep apnoea complicated by sedating substances. On 2 June 2008…

respiratory medicineintensive caredelaydiazepam
VIC2013-08-23

Finding into death of PT

57y · Male·Aspiration pneumonia in an HIV positive man on methadone

…istent with therapeutic use. Key clinical lessons: patients on methadone require careful monitoring for respiratory depression and loss of airway protective reflexes; combined sedating medications increase aspiration ri…

general practicepathologysystemmethadone
NSWhome2023-08-15

Inquest into the death of LA

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

… check on LA 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 o…

paediatricsintensive caredelaycommunicationmethadone
VICmental health2015-07-03

Finding into death of Anthony Travaglini

40y · Male·combined drug toxicity in a man with asthma (undiagnosed) and sleep apnoea

…ticularly benzodiazepines and zuclopenthixol—were inappropriate given his sleep apnoea, which increases respiratory depression risk. Had clinicians accessed his full history or consulted his available family member (a n…

psychiatryrespiratory medicinesystemcommunicationzuclopenthixol
QLDcommunity2019-06-10

Coolwell, Shaun Charles

33y · Male·cardiorespiratory arrest during restraint, involving a predisposition to cardiac…

…digenous man died following police restraint and inappropriate midazolam administration during an acute drug-induced behavioural disturbance. Mr Coolwell sustained injuries while in acute methamphetamine-induced psychosi…

emergency medicinepharmacologydiagnosticcommunicationmethamphetamine
NSWhospital2020-01-31

Inquest into the death of OS

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

… of morphine 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 polypha…

plastic and reconstructive surgeryanaesthesiamedicationproceduralmorphine
VIChome2016-04-04

Finding into death of Frank Edward Frood

47y · Male·Bronchopneumonia on a background of methadone and benzodiazepine use

… He suffered chronic severe asthma and recurrent chest infections. Key clinical issues: (1) Methadone's respiratory depressant effects are contraindicated in severe asthma/respiratory disease per product information and…

general practiceaddiction medicinemedicationsystemmethadone
NSWhome2018-02-23

Inquest into the death of Yongxing Wang

79y · Male·hypoxic brain injury due to cardio-respiratory arrest caused by opioid toxicity

…documentation or monitoring. Wang showed clinical somnolence from 5pm that day—an early warning sign of respiratory depression. The expert consensus was these morphine doses were inappropriate given Wang's age (79), opi…

general practiceradiologymedicationcommunicationmorphine
VIChome2025-12-04

Finding into death of Raymond John Flaherty

57y · Male·Mixed drug toxicity (heroin, methadone, benzodiazepines including novel benzodia…

Raymond John Flaherty, a 57-year-old Wurundjeri man with longstanding opioid and benzodiazepine dependence, died from mixed drug toxicity involving heroin, methadone, prescribed diazepam, unprescribed benzodiazepines inc…

addiction medicinegeneral practicesystemcommunicationheroin
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

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

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…

general practiceaddiction medicinediagnosticcommunicationalprazolam
TAShome2021-12-21

Coroner's Finding: O'Donnell, Margaret Joy

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

Margaret Joy O'Donnell, aged 51, died between 9-15 June 2018. The cause of death could not be determined due to decomposition, but toxicology revealed mixed drug toxicity including fatal levels of methadone and hydromorp…

general practicepsychiatrymedicationsystemoxycodone
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

…g toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prior suicide attempts. On 12 September 2023, she called AC…

psychiatryemergency medicinesystemdelaytapentadol
WAhome2019-06-12

Inquest into the Death of Ellie Marlene HARE

25y · Female·complications of opioid toxicity

Ellie Marlene Hare, 25, died from opioid toxicity after injecting methadone on two consecutive nights with Matthew Drake. She was opioid-naïve, having not used regularly for several years. On the morning of her death, Dr…

toxicologyemergency medicinedelaymethadone
ACTcommunity2016-12-16

An Inquest Into The Death Of Paul Fennessy

21y · Male·combined effect of a cocktail of drugs taken by him, which caused central nervou…

Paul Fennessy, 21 years old, died from a cocktail of drugs causing central nervous system and respiratory depression with positional asphyxia on 6 January 2010. He had a decade-long history of polysubstance ab…

general practiceemergency medicinemedicationproceduralmethadone

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