Coronial

26 results for parental substance abuse disorder

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

…hyxiation from co-sleeping/overlay. Clinical lessons include: recognising SIDS risk factors (co-sleeping, parental substance use); adequate child protection assessment addressing totality of risks; collaborative practice…

paediatricspathologysystemcommunicationcannabis
TAS2021-09-17

Coroner's Finding: Infant Deaths

varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…

…on clinical issues included unsafe infant sleeping environments (co-sleeping, unsafe bedding), inadequate parental engagement with health services, family violence, substance abuse, and parental mental health issues. Cor…

paediatricspsychiatrydiagnosticcommunicationalcohol
NSWhome2014-08-13

Inquest into the death of Sean Leigh MacWilliam

16y · Male·asphyxia due to hanging, self-inflicted, with aspiration of gastric contents as …

…The coroner found the decision to grant leave appropriate but noted planning failures in crisis response, parental supervision clarity, and inter-agency information sharing.

psychiatryemergency medicinecommunicationsystemfluoxetine
WAhome2024-04-04

Inquest into the Death of Child LT (Name Subject to Suppression Order)

11y · Male·unascertained

… The Department of Communities had an open child safety investigation due to concerns about his mother's substance abuse, parental capacity, and neglect. The child was returned to his mother's care despite these concern…

paediatricscardiologycommunicationsystemcocaine
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
VIChome2011-10-31

Finding into death of Rory

4y · Male·Oxycodone toxicity from ingestion of 80mg OxyContin tablet

…of Human Services closed child protection involvement within three months despite substantial evidence of parental drug abuse, inadequate housing, and risk to the children. Key lessons: mandatory supervised medication ma…

general practicepaediatricssystemdelayoxycodone
QLDhome2010-03-05

Child at Mackay

15y · Female·Ligature compression of the neck (hanging)

…unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in substance abuse (paint sniffing, alcohol). She was unsupervised and out late drinking with peers in a park metres …

paediatricspsychiatrysystemdelayalcohol
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
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

…ssues. Critical failures included Queensland DCSSDS inadequately assessing an August 2018 notification of parental aggression, DCJ failing to conduct a review safety assessment after receiving information about untreated…

paediatricspsychiatrysystemcommunication
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

…spite high-risk circumstances including prior removal of the mother's first child, domestic violence, and parental mental health issues. Brighter Futures' practitioner, despite observing concerning signs of parental subs…

paediatricspsychiatrydiagnosticcommunicationquetiapine
VIChome2014-07-18

Finding into death of Shyra Lee Bloomfield

16y · Female·hanging

… died by hanging after an episode of inhalant ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement from education. While Child …

paediatricsaddiction medicinesystemcommunicationinhalant
WAcommunity2011-10-21

Inquest into the Death of Balgo

Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…

… Balgo Aboriginal Community over a 24-month period: four suicides by hanging and one death from volatile substance abuse. The suicide rate in Balgo was more than 100 times the state average, constituting a cluster. The …

general practicepsychiatrysystemdelaypetrol
VICmental health2022-12-13

Finding into death of Jamie Andrew Kowalewsky

27y · Male·Global cerebral ischaemic injury in the setting of hanging

Jamie Kowalewsky, a 27-year-old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide attempt, was voluntarily admitted to a low dependency psy…

psychiatryintensive carecommunicationlorazepam
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

0y · Female·Sudden infant death whilst bed-sharing with risk factors including unsafe sleepi…

…proper child protection protocols been followed, the infant would almost certainly have been removed from parental care. Clinical lessons: safe-sleeping advice must be reinforced with at-risk families; multidisciplinary …

paediatricsforensic medicinesystemdelaymorphine
WAcommunity2002-07-19

Inquest into the Death of Elizabeth Ann Studd

33y · Female·Immersion (drowning) by suicide

Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severely traumatic childhood characteris…

psychiatrygeneral practicealprazolam
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a traum…

paediatricspsychiatrydiagnosticcommunicationcannabis
SAhome2000-09-15

Coroner's Finding: DONAGHEY Luke Francis

26y · Male·.357 magnum gunshot wounds to the chest and abdomen

Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…

general practicepsychiatrydiagnosticcommunicationhaloperidol
WAhospital2018-06-25

Inquest into the Death of LCTM

0y · Male·complications of head injury

…is teenage father in hospital on 15 February 2014. The father had a well-documented history of violence, substance abuse, criminality and had been in Department of Child Protection care. Pre-birth planning was delayed d…

neonatologypaediatricscommunicationsystem
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine
VICcommunity2012-03-01

Finding into death of K

33y · Male·complications from blunt force trauma to head consequent upon being struck by a …

A 33-year-old man with long-standing substance abuse and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007…

psychiatrygeneral practicediagnosticcommunicationmethadone

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