Coronial

10 results for parental substance dependence

QLDhome2015-04-24

Lievesley, Tamiya Calais

0y · Female·Morphine toxicity

… prescribing doctor (Dr S.) 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 ser…

paediatricsgeneral practicemedicationdiagnosticmorphine
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
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…

…ate care following removal 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 supe…

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
QLDhome2021-02-17

T, an eight week old infant - Non-inquest findings

0y · Male·Sudden infant death syndrome category II (SIDS) - accidental asphyxiation due to…

…e and unsafe sleep practices were ignored by child protection officers who lacked expertise in assessing substance dependence impacts on parenting capacity. Had information been properly weighted and integrated, the chi…

neonatologypaediatricssystemcommunicationheroin
VIChome2025-02-07

Finding into death of T

15y · Male·Combined heroin and methamphetamine toxicity

… 2019. He had experienced multiple placement instability (over 20 placements in two years), early trauma, parental substance use history, and escalating mental health issues including suicidal ideation. Despite referrals…

paediatricspsychiatrycommunicationsystemheroin
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…

general practicepsychiatrydiagnosticcommunicationfluoxetine
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
NSWhospital2026-01-22

Inquest into the death of JC

30y · Male·hanging

JC was a 30-year-old with a long history of benzodiazepine dependence and previous psychiatric episodes triggered by withdrawal. He presented to Calvary Mater Hospital after …

emergency medicinepsychiatrydiagnosticcommunicationetizolam
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric dischar…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate

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