50 results
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 a deliberate overdose of 48 Etizolam tablets w…
43y · Male·methadone toxicity
Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
33y · Male·stab wound to the chest
Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell …
31y · Male·Drowning
Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…
3y · Male·unascertained
KP was a 3-month-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 fol…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
37y · Male·Cardiomegaly giving rise to lethal cardiac arrhythmia in the setting of drug tox…
37-year-old Robert Phair died in Parklea Correctional Centre from cardiomegaly causing lethal cardiac arrhythmia in the setting of drug toxicity. He was placed in detoxification requiring four-hourly clinical observation…
37y · Male·multiple gunshot wounds
Brett Walker, 37, was shot by police on 9 July 2022 after a domestic violence incident 23 days post-release from prison. He had long-standing drug addiction and mental health issues including paranoid ideation, particula…
65y · Male·Cardiac arrhythmia, probably Torsades de Pointes, due to the combined effects of…
Linus Phillips, age 65, died at home in October 2014 from cardiac arrhythmia (Torsades de Pointes) precipitated by methadone prescribed with inadequate oversight. Mr Phillips had chronic pain from knee surgery, severe sl…
6y · Unknown·methadone toxicity
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
33y · Male·Complications of methylamphetamine use
Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…
43y · Male·The combined effects of subacute myocardial injury and methadone toxicity
Timothy Ricketts, a 43-year-old man with complex psychiatric and substance use history, died from combined subacute myocardial injury and methadone toxicity. He had been admitted to hospital in November 2021 with elevate…
33y · Male·Hanging
CC, a 33-year-old First Nations man with methamphetamine-induced bipolar disorder and psychosis, was admitted to the High Dependency Unit at Nepean Hospital on 7 June 2022 under involuntary mental health detention. Over …
5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity
LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…
33y · Male·Prolonged epileptic seizure resulting in gastric content aspiration and cardiac …
Roy Roberts, a 33-year-old Aboriginal man, died at Long Bay Correctional Complex from a prolonged epileptic seizure resulting in aspiration and cardiac arrest. He had experienced three prior seizure-like episodes in Apri…
41y · Male·Cardiomegaly and Coronary Artery Disease with significant contributing condition…
Jay Crich, a 41-year-old man in custody at Clarence Correctional Centre, died of cardiomegaly and coronary artery disease with emphysema and obesity as significant contributing conditions. He was discovered unresponsive …
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