51y · Female·unascertained
…eing held at Bendigo Police Station. She had been brought to Bendigo Hospital on 20 April with symptoms of opioid withdrawal and anxiety, and was discharged back to custody with diazepam 5mg prescribed three times daily.…
37y · Female·Mixed drug toxicity (methadone, diazepam, clonazepam, amisulpride, olanzapine, h…
…xicity. The coroner found critical departures from clinical guidelines: inadequate objective assessment of opioid withdrawal (patient heavily sedated, masking withdrawal signs), inappropriate rapid dose titration, insuff…
43y · Male·Unascertained - attributed to metabolic/physiological derangement in context of …
…as appropriately scheduled for medical review. On the following day, he developed vomiting consistent with opioid withdrawal and was assessed by a doctor and nurse, both finding standard withdrawal presentation without s…
38y · Male·Multidrug toxicity
A 38-year-old man with multiple drug dependencies (alcohol, opioids, benzodiazepines) was admitted to a drug withdrawal facility for assisted detoxification. He received bup…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
…icity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioid naive despite representations of heroin use and prescribed 30 mg methadone daily after two doses. The coro…
32y · Male·hypoxic brain injury from hanging in custody
…er checks, failure to prioritize placement to facilities offering 24-hour medical care during acute drug withdrawal, and insufficient officer training in recognizing withdrawal symptoms. The coroner applied the 'Swiss Ch…
37y · Female·complications of withdrawal from chronic opiate use and Wilkie Syndrome in the s…
Veronica Nelson, a 37-year-old Aboriginal woman with opioid dependence, was arrested on minor theft charges, remanded in custody following a bail hearing, and held at…
47y · Male·Intracerebral haemorrhage secondary to heroin withdrawal in a patient with sever…
…custody. He was held in the Southport watch house for 55 hours before collapsing. Nursing staff identified opioid withdrawal symptoms and prescribed diazepam 10mg three times daily, but administration was delayed 32 hour…
35y · Male·heroin toxicity
…ound no suspicious circumstances or suicide indicators. Clinical lessons include recognising urgent drug withdrawal symptoms, the importance of rapid appointment access for opioid-dependent patients requesting help, and …
40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…
… concerns about his altered consciousness, he was cleared for police custody. In prison, he presented with opioid withdrawal symptoms, minimal oral intake, drowsiness, and difficulty mobilising. Despite appropriate medic…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
…arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical delays occurred: an ambulance was not called immediately after his first collapse at …
0y · Female·undetermined; possible suffocation not definitively established at autopsy
…was considered possible. The infant was born prematurely on a concrete pavement to a mother with untreated opioid addiction and homelessness. Despite hospital social work concerns, discharge planning lacked clarity about…
42y · Male·unascertained
…er in general practice without adequate specialist oversight, particularly regarding dose escalation and withdrawal planning.
28y · Female·methadone toxicity
…as within guidelines, the coroner noted that 40mg is considered a high starting dose, and benzodiazepine withdrawal noted in her clinical notes suggested lower doses (20-30mg) would have been more appropriate. She receiv…
26y · Male·gastric aspiration
…anded prisoner died from gastric aspiration at Adelaide Remand Centre. He was a heroin user experiencing withdrawal, having been offered but declined infirmary treatment and methadone on arrival. Cellmate observations no…
65y · Male·hypoxic ischaemic encephalopathy complicating hanging
…nt Order. However, psychiatrist Dr O. incorrectly revoked the order the next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included:…
29y · Male·Mixed drug toxicity (heroin and methamphetamine)
…amphetamine addiction died from mixed drug toxicity. He had suffered a work-related back injury leading to opioid dependence, complicated by anxiety and panic attacks. Although engaged with psychological and drug and alc…
29y · Male·mixed drug toxicity including heroin
Troy Daniel Saint, a 29-year-old man with amphetamine and opioid dependence, died of mixed drug toxicity including heroin while admitted to The Melbourne Clinic for volunt…
29y · Male·multiple drug toxicity (buprenorphine, oxazepam, diazepam, alprazolam, and methy…
… contributed to this preventable death: prison health services failed to communicate his documented drug withdrawal treatment and ongoing substance use to community corrections supervisors, who remained unaware he was a …
36y · Female·Mixed drug toxicity
…d drug toxicity after being discharged from Maroondah Hospital on 8 March 2017. She had been admitted with opioid withdrawal, depression, and suicidal ideation. Hospital discharge planning included community follow-up, a…
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