Coronial

99 results for medication misuse

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 prescribed high-risk combinatio…

general practicepain medicineoxycodone
VICcommunity2021-03-10

Finding into death of Casey Evan Cahill

19y · Male·Multiple injuries sustained on a train impact (pedestrian)

… of mental ill health including depression, psychotic symptoms, and suicidal ideation, alongside substance misuse involving methamphetamine, cannabis, cocaine, and alcohol. He was enrolled in the Headspace Youth Early Ps…

psychiatryaddiction medicinesystemalcohol
TAShome2018-11-16

Coroner's Finding: Taylor, Michael John

50y · Male·methadone and alprazolam intoxication

…oximately 1.5 hours after becoming heavily intoxicated. Police records from 2009-2011 indicated possible medication distribution and drug misuse, but this information was not shared with his GP or the Pharmaceutical Serv…

general practicepain medicinecommunicationsystemmethadone
VIC2022-09-09

Finding into death of Gregory Paul Sedgman

42y · Male·Complications post polypharmacy toxicity

Gregory Sedgman, aged 42, died from polypharmacy toxicity after consuming excessive prescription medications at a post-sentence supervision residential facility. He had deliberately accumulated medications despit…

psychiatrytoxicologymedicationcommunicationoxycodone
ACThome2017-09-11

AN INQUEST INTO THE DEATH OF LESLEY MAREE SMITH

47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)

Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., …

general practicepathologydiagnosticcommunicationdiazepam
SAhome2010-06-04

Coroner's Finding: ARBUCKLE Claudia Anna Maria

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

…sion died from mixed drug toxicity with aspiration of gastric contents. She had been prescribed multiple medications including amitriptyline, diazepam, codeine, and lorazepam, with post-mortem toxicology showing potentia…

general practicepain medicineamitriptyline
TAShome2023-05-01

Coroner's Finding: Koeter, Jacqueline Francis

59y · Female·Global hypoxic brain injury due to mixed drug toxicity, specifically alprazolam …

…ed by mixed drug toxicity, with alprazolam levels in the fatal range. She had intentionally taken excess medication on 28 September 2021 before receiving a COVID-19 vaccine dose, a pattern her daughter recognised as copi…

general practicepsychiatryalprazolam
VIChome2019-10-07

Finding into death of Phillip James King

52y · Male·Mixed drug toxicity

…ing for all drugs including pregabalin; coordinating prescribing across multiple clinicians; recognising medication misuse in patients with legitimate chronic pain; and recognising overdose signs (abnormal breathing, una…

general practiceneurologymedicationcommunicationfentanyl
TAShome2018-09-20

Coroner's Finding: Steer, Michael Allan

44y · Male·mixed drug toxicity

Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and soma…

general practicepsychiatrydiagnosticcommunicationquetiapine
QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

…oxicity or fatal arrhythmia were likely. He had been assaulted in custody and was on multiple prescribed medications (mirtazapine, escitalopram, diazepam, pregabalin, baclofen) but also accessed non-prescribed medication

psychiatrycorrectional healthsystemdiazepam
WAhospital2013-09-05

Inquest into the Death of Fisher, Hayley Bree

27y · Female·opiate toxicity (fentanyl)

…tained from a patient-controlled analgesia device. She had a history of depression, anxiety, and substance misuse following her mother's death, and was on multiple psychiatric medications. The coroner found no evidence o…

obstetricsanaesthesiasystemfentanyl
VIC2019-10-18

Finding into death of Mr A

24y · Male·Mixed drug toxicity

…el. He had a history of anxiety and shoulder pain following 2015 surgery, for which he received multiple medications including pregabalin, benzodiazepines, opioids, and stimulants from different prescribers. His girlfrie…

psychiatrygeneral practicecommunicationsystempregabalin
VIChome2014-04-02

Finding into death of AB

34y · Female·Combined drug toxicity (propofol, sevoflurane and others)

…ed trolleys accessible to all theatre staff; (2) failure of her GP and employer to recognise her substance misuse and mental health deterioration; (3) her declining psychiatric follow-up despite referral in 2010 and advi…

anaesthesiageneral practicesystemcommunicationpropofol
TASmental health2024-02-08

Coroner's Finding: de-identified PU

45y · Male·hanging

A 45-year-old man with a history of depression, suicidal ideation, and alcohol misuse was admitted to Spencer Clinic following a medication overdose suicide attempt. During his six-day admissi…

psychiatrygeneral practice
VIChome2018-07-29

Finding into death of Diane Maria Hillgrove

34y · Female·Mixed drug toxicity

…acy pickups and prescription monitoring, she obtained pregabalin from multiple doctors and used diverted medications. On 6 July, Dr V. appropriately increased her pregabalin to 150mg for acute abdominal pain, but she lik…

general practicepsychiatrysystempregabalin
TAScommunity2016-05-25

Coroner's Finding: Barnes, Deearne Joan

53y · Female·mixed prescription drug toxicity

…dispensing of methadone, did not conduct adequate risk assessment despite documented prior overdoses and medication misuse, and inappropriately continued polypharmacy with multiple CNS depressants. Critical clinical fail…

psychiatrypain medicinediagnosticmedicationvenlafaxine
TAShome2016-12-05

Coroner's Finding: Lunson, Nathan

24y · Male·mixed ethanol and prescription drug toxicity

… a relationship conflict on 10-11 January 2015, he consumed large quantities of alcohol and prescription medications (tramadol, endone, diazepam, and others). Clinically, this case highlights the challenges managing youn…

psychiatrypsychologyalcohol
VICcommunity2019-02-25

Finding into death of DH

40y · Female·Clozapine toxicity in a woman with cardiomegaly

…ervision, combined with benzodiazepines and alcohol. Clinical lessons include: PRCs must actively manage medication sharing and alcohol use despite promoting resident independence; family relationships are protective fac…

psychiatrygeneral practicesystemcommunicationclozapine
VIChome2020-06-12

Finding into death of Daniel Isaac Semple

39y · Male·Multiple drug toxicity (methadone, diazepam, oxazepam, carbamazepine, levetirace…

…ssess suitability for unsupervised dosing, and failure to detect or act on evidence of methadone injection misuse. The prescribing GP failed to implement planned benzodiazepine tapering and continued takeaway dosing desp…

general practiceaddiction medicinediagnosticmedicationmethadone
VICprison2020-12-23

Finding into death of Gary Hietanen

45y · Male·Combined drug toxicity (methadone, amitriptyline, gabapentin, paracetamol)

…itriptyline, gabapentin and paracetamol. He had a documented history of hoarding and misusing prescribed medications to achieve a euphoric effect. He was admitted to hospital on 21 July 2017 after deliberately overdosing…

emergency medicinecardiologycommunicationsystemmethadone

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