Coronial

28 results for parental substance use 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

…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
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
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
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
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
VICcommunity2023-11-24

Finding into death of Geelong Youth Suicide Cluster Finding

Male·suicide

…ng relationship breakdowns, mental health deterioration, family stressors, educational difficulties, and substance use. Most were engaged with mental health services. Common protective and risk factors included social i…

psychiatrygeneral practice
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 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
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
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
VICcommunity2021-03-10

Finding into death of Casey Evan Cahill

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

… history 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…

psychiatryaddiction medicinesystemalcohol
TAShome2018-12-17

Coroner's Finding: Pitchford, Rhiannon Pearl Vanessa

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

…intoxicated by intravenous morphine and methamphetamine, remained nearby. The autopsy revealed no obvious cause, but documented face-down positioning, respiratory infection, passive smoking exposure, and unsafe sleep en…

paediatricsforensic medicinesystemdelaymorphine
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
SAhome2000-09-15

Coroner's Finding: DONAGHEY Luke Francis

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

…er failed to utilize available mental health services despite clear evidence of florid psychosis. The GP refused detention under the Mental Health Act, believing the patient would deny symptoms to others, and instead ad…

general practicepsychiatrydiagnosticcommunicationhaloperidol
VIC2016-04-14

Finding into death of Oscar Nicholas McIntyre

17y · Male·injuries sustained in a motorcycle incident (driver)

…y medication. Post-mortem toxicology detected amphetamines and metabolites at low levels. While the exact cause of his decision to leave the track is unknown, the coroner noted amphetamines can impair riding ability and…

psychiatrygeneral practicemethamphetamine
VIChome2014-07-18

Finding into death of Shyra Lee Bloomfield

16y · Female·hanging

A 16-year-old Aboriginal girl died by hanging after an episode of inhalant ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficult…

paediatricsaddiction medicinesystemcommunicationinhalant
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
WAhome2019-06-12

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

13y · Male·Epileptic seizure with aspiration

Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…

neurologypaediatricsmedicationcommunicationlevetiracetam
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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