Coronial

15 results for maternal substance use disorder

VIChospital2018-10-05

Finding into death of Baby W

Female·Intrauterine pneumonia and meconium aspiration complicating intrauterine growth …

…om intrauterine pneumonia and meconium aspiration secondary to intrauterine growth restriction related to maternal amphetamine use. The mother had known substance abuse, prior child protection involvement, and tested pos…

obstetricsneonatologydiagnosticsystemmethamphetamine
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experienci…

psychiatrypaediatricssystemcommunicationfluoxetine
WAcommunity

Inquest into the Death of Paul DICKSON

34y · Male·multiple injuries

…Graylands Hospital on 31 October 2013 following treatment for a relapse of schizophrenia precipitated by substance abuse. His mother had died in mid-2013, a significant psychosocial stressor. Community follow-up by Osbo…

psychiatryemergency medicineolanzapine
QLDhome2021-02-17

B, an eleven week old infant - Non-inquest findings

0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying

…0am; the baby was discovered head-down beside the bed at 6:30am. Autopsy could not conclusively determine cause of death but indicated probable SIDS or asphyxiation from co-sleeping/overlay. Clinical lessons include: re…

paediatricspathologysystemcommunicationcannabis
NSWhome2025-05-30

Inquest into the Death of K.P.

3y · Male·unascertained

…old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coordination and follow-up were subo…

paediatricspsychiatrysystemcommunicationcannabis
NSWhome2018-06-08

Inquest into the death of BL GN and D G

Female·Sudden Unexpected Death in Infancy (SUDI), otherwise undetermined

…9 days of age. Both deaths were classified as Sudden Unexpected Death in Infancy (SUDI) with undetermined cause. The coroner identified systemic failures in child protection services: numerous abuse and neglect reports …

paediatricsneonatologysystemdelayice/methamphetamine
QLDcommunity2016-05-03

Foster, Troy Martin

32y · Male·gunshot wounds to the trunk

…rtin Foster, a 32-year-old man with intellectual impairment, mild cognitive disability, and a history of substance abuse and violence, died following a police shooting. On 24 November 2014, he was detained under a Menta…

psychiatryemergency medicinecommunicationsystemalcohol
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

… months in each case), inadequate risk assessment despite identified high-risk factors (family violence, substance use, mental health issues, parental inability to care for other children), failure to provide safe sleep…

paediatricspsychiatrydiagnosticcommunicationmethadone
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

…psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child was found unresponsive after co-sleeping with her father in a warm bedroom. Multiple SIDS risk f…

paediatricspsychiatrysystemdelay
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hos…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
WAhospital2025-04-17

Inquest into the Deaths of HC and Child HR

terminal palliative care in a girl with a clinical diagnosis of aspiration pneum…

…val from her mother's care. Her mother, HC, had chronic benzodiazepine and opioid dependence, presenting substance-affected whilst caring for her profoundly disabled daughter who required 24/7 supervision and assistance…

paediatricspalliative care
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

Amanda Kennedy, a 26-year-old woman with a history of trauma, substance abuse, depression, and multiple suicide attempts, died by hanging in the Northern Psychiatry Unit on 24 …

psychiatryemergency medicinecommunicationsystemquetiapine
NSWcommunity2022-07-15

Inquest into the death of C S

5y · Male·Presumed drowning

…ite clear risk factors: LS's recent release from prison, history of violence and mental health issues, drug use, erratic behaviour, and SJ's expressed concerns she would take the children. Mental health and police respo…

paediatricspsychiatrydiagnosticsystemmethamphetamine
VICcommunity2015-05-07

Finding into death of Krisinda Carmen Smart

15y · Female·toxicity to heroin

Krisinda Carmen Smart, aged 15, died from heroin toxicity on 20 January 2008. She was a child in care of the Department of Human Services subject to a Custody to Secretary Order. In the days before her death, there were …

paediatricsemergency medicinediagnosticsystemheroin
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

…approach inconsistent with other security restrictions. Corrections Victoria made inadequate responses to maternal concerns and failed to fulfil commitments made to the supervising judge.

addiction medicinepsychiatrymedicationsystemmethadone

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