Coronial — Australian Coroners Findings

26 results for “home-seeking behaviour”

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NSWcommunity2021-12-21

Inquest into the deaths of Lars FALKHOLT, Vivian FALKHOLT, Jessica FALKHOLT and Annabelle FALKHOLT, and Craig WHITALL

Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…

Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …

general practiceemergency medicinemedicationcommunicationmethadone

NSWhospital2022-03-11

Inquest into the death of Kelvin Forrest

53y · Male·multiple injuries sustained in a fall from the first floor

…t awaiting NDIS funding approval for supported independent living. Despite documented frequent wandering behaviour, including an incident where he was found on the road outside the hospital, supervision was inadequate. …

general medicinegeriatric medicinediagnosticcommunication

VIChome2015-06-23

Finding into death of Terri Anne Woolley-Peresso

44y · Female·Unascertained

… the Drugs and Poisons Regulation (DPR) Help Line, which would have revealed her history of drug-seeking behaviour and existing ORT prescriptions. An Addiction Medicine Unit had recently advised against opioid prescribi…

general practiceaddiction medicinediagnosticmedicationdiazepam

QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

…failing to recognize and appropriately manage the parents' escalating opioid dependence and drug-seeking behaviour despite clear warning signs; failure to refer them to addiction treatment services; police investigating…

paediatricsgeneral practicemedicationdiagnosticmorphine

TAShome2020-05-19

Coroner's Finding: Adams, Christopher Neil

31y · Male·mixed prescription drug toxicity (methadone, fluvoxamine, tramadol, mirtazapine …

… history of opioid addiction, multiple emergency presentations for medication overdose, and drug-seeking behaviour managed by his GP and pharmacy services. Despite safeguards (locked medication storage), he obtained all…

general practiceemergency medicinesystemmethadone

QLDhome2014-11-26

Smith, Rachel Danielle - Non-inquest findings

25y · Female·mixed drug toxicity

Rachel Smith, a 25-year-old woman with chronic migraines and depression, died from mixed drug toxicity after consuming multiple prescription medications including oxycodone, codeine, tramadol, diazepam, amitriptyline and…

general practiceneurologydiagnosticsystemoxycodone

VIChome2017-08-16

Finding into death of CPLH

32y · Male·Multidrug overdose

…hadone, and other drugs from multiple prescribers and pharmacies. While some GPs recognised drug-seeking behaviour and ceased prescribing, others (notably Dr S.) continued providing high-risk prescriptions as recently a…

general practiceemergency medicinesystemcommunicationfentanyl

QLDhome2019-07-15

Male child aged 20 months - Non-inquest findings

20y · Male·Lung infection on a background of oxycodone intoxication

…l importance of real-time prescription monitoring systems, practitioner vigilance regarding drug-seeking behaviour, and proper assessment of drug dependence before prescribing Schedule 8 substances.

general practiceforensic medicinediagnosticmedicationoxycodone

VIChome2023-10-02

Finding into death of Student XRG

22y · Male·Neck compression by ligature suspension (hanging)

A 22-year-old international student from India died by hanging at his home in Victoria. He was studying information technology at Monash University after experiencing academic difficulties, having failed multiple subject…

psychiatrypsychologysystem

VIChome

Finding into death of Juana Legge

29y · Female·Multiple stab injuries to the chest

Juana Legge, a 29-year-old Sudanese-born woman, was fatally stabbed on 24 August 2010 by her husband Lino Mamour in their Dandenong home. The killing occurred after Mamour became convinced, without evidence, that Juana w…

alcohol

TASaged care2023-05-22

Coroner's Finding: Courtney, Wesley Paton

84y · Male·Head and neck injuries sustained in a fall; specifically facial bone fractures a…

…siotherapy assessment, mobility aids, and staff awareness of his high fall risk and impulsive ambulation behaviour. The coroner found the aged care facility employed all reasonable falls prevention strategies and that s…

geriatric medicineemergency medicine

NSWhome2019-02-26

Inquest into the death of Emily

Female·self-inflicted death

… about children's mental health needs and past clinicians; (3) Foster carers need training on adolescent behavioural changes linked to trauma and attachment issues; (4) Significant care plan changes (adoption hold) requ…

psychologypsychiatrycommunicationsystem

NSWhome2019-02-15

Inquest into the death of Margaret Rose CARR

62y · Female·Unknown. Likely natural causes, possibly with drug-related element. QT-prolongat…

Margaret Carr, 62, was found dead at her home in Redfern between 27 February and 1 March 2017. She had complex medical history including COPD, endocarditis, hepatitis C and substance use disorder (heroin, cannabis, metha…

general practiceforensic medicineamitriptyline

QLDhospital2018-07-30

Matthew Douglas McLachlan - Non-inquest findings

28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…

…tient status before prescribing opioids; hospital staff should maintain higher suspicion of drug-seeking behaviour in patients with acknowledged opioid dependency and previous intravenous drug use; coordinated pain mana…

infectious diseasesemergency medicinecommunicationsystemfentanyl

VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

…suffocating them, then died by suicide. The family had unrecognised history of controlling and isolating behaviours by the father toward the mother. Critical lessons include: healthcare professionals seeing both spouses…

rehabilitation medicineneurologycommunicationsystemchloroform

VIChospital2017-12-11

Finding into death of Karen Ann Moore

49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…

Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…

general practiceemergency medicinemedicationcommunicationoxycodone

VICcommunity2014-02-07

Finding into death of Bayden Joel Quilkey

30y · Male·unascertained

Bayden Quilkey, 30, died from unascertained causes on 13 March 2008 during an acute psychotic episode while being restrained by police. He had recently moved from Queensland showing signs of paranoid schizophrenia with s…

psychiatryemergency medicinesystemcommunication

TASaged care2023-08-07

Coroner's Finding: Colpo, Dario

92y · Male·left haemothorax and rib fractures resulting from a fall at a residential aged c…

A 92-year-old man with multiple comorbidities (cardiac failure, COPD, chronic renal failure, diabetes) and documented high falls risk sustained a fall at a residential aged care facility on 12 May 2021, resulting in left…

geriatric medicinephysiotherapysystemproceduralrivaroxaban

NSWhome2018-05-25

Inquest into the death of J

0y · Female·Unascertained

…d three days before her death. The report documented overcrowding, poor hygiene, and aggressive parental behaviour. The 24-hour risk assessment was not completed; instead, the matter was deferred to a weekly allocation …

paediatricsgeneral practicesystemdelay

VIChome2014-06-12

Finding into death of Maree Arthur

45y · Female·Pethidine toxicity

Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr P., prescribed large quantities of pethidine and ox…

general practicepain medicinemedicationdiagnosticpethidine

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