Coronial
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

…1 July 2014, despite being on hourly observations and deteriorating mental state that evening (agitation, tremors after ceasing medication for ECT), he was allowed accompanied leave with his partner. The hospital's ther…

psychiatrysystemcommunicationcitalopram
VIChome2023-06-28

Finding into death of Kelvin Maurice Jeffery

96y · Male·Blunt chest trauma from quad bike accident

…uad bike accident on his rural property. He had declined in health with poor eyesight, kyphosis, and hand tremors, prompting him to stop driving his car. He chose to ride a quad bike without a roll bar (for better visib…

emergency medicineintensive caresystem
NSWhospital2016-11-22

Inquest into the deaths of Sandra BONEY, Norman BONEY and Roger John ADAMS

Organising pneumonia (Sandra Boney and Norman Boney); Organising pneumonia compl…

…ion and were diagnosed initially as alcohol withdrawal. Clinical features included altered consciousness, tremors, vomiting, visual disturbances, and signs of methanol toxicity including acidosis. All subsequently devel…

toxicologyemergency medicinediagnosticdelaymethanol
SAaged care2014-03-21

Coroner's Finding: MORGAN Beryl Jean

73y · Female·pneumonia and renal failure with hyperthermia

…iple failures in her care: inadequate monitoring for dehydration despite clinical signs (severe sweating, tremors, elevated blood sugars), delayed medical review by her GP (Dr G.), inappropriate use of intramail for urg…

general practicegeriatric medicinediagnosticcommunicationhaloperidol
VIC2020-01-29

Finding into death of Prisoner A

55y · Male·Ischaemic heart disease in a man with multiple system atrophy (Parkinsonian type…

…disease and multiple system atrophy (MSA) died suddenly in custody from natural causes. He presented with tremors and collapse in 2017, and was appropriately diagnosed with MSA Parkinsonian type by 2018. MSA is a rare, …

cardiologyneurologylevetiracetam
VIChome2015-05-31

Finding into death of Suzanne Berg

62y · Female·unascertained

Suzanne Berg, a 62-year-old woman with schizophrenia, died in her home between January and May 2013 with an unascertained cause. She had a long history of disengaging from treatment despite having medication-controlled d…

general practicepsychiatrysystemzuclopenthixol
SAmental health2009-12-04

Coroner's Finding: BLUNDEN Peter Ross

54y · Male·hanging by ligature

Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his adm…

psychiatryemergency medicinecommunicationsystemoxazepam
WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

… and abnormal movements deteriorated markedly. He was admitted to hospital on 31 October 2001 with severe tremors, fever, and dystonic reactions. Despite treatment with benztropine and benzodiazepines, he died suddenly …

general practicepsychiatrythioridazine
VICaged care2021-05-24

Finding into death of Julie-Anne Marie Kettle

56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels

…for fluid retention. Despite GP reviews showing clinical signs concerning for lithium toxicity (lethargy, tremors, nausea, poor appetite), her lithium level was not rechecked between December 2017 and early March 2018. …

general practicepsychiatrydiagnosticdelaylithium
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…

psychiatrygeneral practicecommunicationsystemrisperidone
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

…suicide risk was assessed as low, his parents later reported concerning medication side effects including tremors and breathing difficulty. The coroner found the discharge plan compromised but could not conclude that co…

psychiatryintensive carecommunicationsystempaliperidone

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