Coronial
WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

…ber 2000, his GP discontinued Mellaril due to its well-documented severe long-term side effects (tardive dyskinesia), and switched him to newer atypical antipsychotics. Despite multiple medication adjustments by both his…

general practicepsychiatrythioridazine
WAmental health2015-11-18

Inquest into the Death of Anna Maria CAMERON

65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…

… psychiatric condition involved impulsivity and long-term antipsychotic use may have caused mild tardive dyskinesia affecting swallowing coordination. Medical response was appropriate and timely. The death was deemed a t…

psychiatryintensive carelorazepam
SAhome2026-07-07

Coroner's Finding: Morland-Shearer, Debra

64y · Female·choking on food on a background of Alzheimer's disease and antipsychotic therapy

Debra Jayne Morland-Shearer, aged 64, died on 11 January 2023 from choking on food while living in supported community care under a Guardianship Order. She had Alzheimer's disease, mild dysphagia diagnosed in November 20…

speech pathologypsychiatryquetiapine
NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

…h ward. He had been stable on depot antipsychotic medication for several years before developing tardive dyskinesia. His treating psychiatrist ceased the medication to address this severe side effect, and he relapsed wit…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
NSWhospital2021-12-23

Inquest into the death of Shelley YOUNG

65y · Female·choking on a tangerine

…ctive disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine while an inpatient at Manly Hospital. She had documented choking risk …

psychiatrygeriatric medicinecommunicationsystemclozapine
VIChospital2025-09-30

Finding into death of Richard Mark Ellis

64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…

Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…

emergency medicinepsychiatryamisulpride
WAcommunity

Inquest into the Death of Kim Martin FRANKER

36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…

…nd undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive dyskinesia), amphetamine-type stimulants, and dehydration with renal impairment. He was on a community treatment or…

psychiatrygeneral practicecommunicationsystembenzhexol
VICaged care

Finding into death of Marjorie Helen McGibbony

75y · Female·Hypostatic bronchopneumonia in the setting of dementia

A 75-year-old woman with intellectual disability, dementia, and asplenia died from hypostatic bronchopneumonia. She had been declining since April 2016 with progressive weight loss, increased agitation, falls, and swallo…

geriatric medicinepalliative care
SAaged care2017-08-25

Coroner's Finding: WEIR Maureen Mary

79y · Female·General inanition due to advanced vascular dementia on a background of ischaemic…

Maureen Mary Weir, aged 79, died of general inanition due to advanced vascular dementia with background ischaemic heart disease and chronic lymphatic leukaemia. She was a resident at Kapara Nursing Home under a Guardians…

geriatric medicinepalliative care
TAScommunity2026-04-27

Coroner's Finding: de-identified TP

32y · Male·multiple injuries caused by a single vehicle crash

A 32-year-old man with long-standing methamphetamine addiction and drug-induced psychosis died in a motor vehicle crash on 6 January 2024. Although he received hospital treatment for severe psychosis in August 2023 and w…

general practicepsychiatrymethamphetamine
WAhospital2005-03

Inquest into the Death of Bert Sharpe

58y · Male·Gastrointestinal haemorrhage due to erosive gastritis

Bert Sharpe, aged 58, died from gastrointestinal haemorrhage due to erosive gastritis at Sir Charles Gairdner Hospital on 19 April 2004. He had been an involuntary psychiatric patient at Graylands Hospital since 1992, fo…

psychiatrygeneral surgery
VIChospital2023-06-25

Finding into death of Peter John Weatherly

63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…

A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…

general medicineemergency medicinesystemcommunicationrisperidone
VIChome2022-08-11

Finding into death of Christopher David French Hunter

31y · Male·hanging

Christopher Hunter, a 31-year-old with emerging paranoid psychotic disorder, was admitted to Delmont Private Hospital for 3 days before requesting discharge against medical advice on 9 June 2015. A senior registrar (Dr T…

psychiatrycommunicationsystemolanzapine
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…

psychiatrygeneral practicediagnosticmedicationolanzapine
NTmental health2025-02-14

Inquest into the death of Pukumani

47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…

Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…

psychiatryemergency medicinediagnosticcommunicationketamine
SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol

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