28 results
63y · Male·pulmonary emphysema
Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Treatment Order. He had advanced COAD diagnosed only one mon…
39y · Female·multiple drug toxicity (etizolam and carisoprodol as major components)
Catherine Broadbent, 39, died from multiple drug toxicity involving benzodiazepines (etizolam, carisoprodol) sourced from the dark web, in the context of chronic borderline personality disorder and complex PTSD with life…
18y · Male·asphyxia by hanging; intentional self-harm
Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…
83y · Female·pneumonia with generalised atherosclerosis as a significant contributor
Pamela Vance, 83, died from pneumonia with generalised atherosclerosis as a significant contributor. She had multiple comorbidities including COPD, asthma, sleep apnoea and heart disease, complicated by recent falls and …
9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…
Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …
30y · Male·unascertained
Daniel James Clement, a 30-year-old man with schizophrenia on a Psychiatric Treatment Order, disappeared from his mother's home in late May 2017 and was found deceased on the Murrumbidgee River in November 2017. His caus…
53y · Female·Combined effects of alcohol, amitriptyline, and methadone
Joanne Lovelock, a 53-year-old woman with chronic pain, died from combined effects of alcohol, amitriptyline, and methadone on Christmas Day 2015. She had developed opioid dependence while receiving legitimate pain manag…
67y · Male·aspiration of gastric contents, due to morphine toxicity, in the context of bila…
A 67-year-old man with chronic pain, pancreatitis, osteoporosis and emphysema died from aspiration of gastric contents due to morphine toxicity. He had been prescribed opioid medications (MS-Contin and Ordine) by his GP …
68y · Female·Plastic bag asphyxia with vitiated atmosphere, with Motor Neuron Disease being a…
A 68-year-old woman with Motor Neuron Disease died from asphyxia on 15 March 2019. She had been diagnosed with MND in 2016 and experienced progressive disability requiring wheelchair use and assistance with activities of…
36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…
Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…
52y · Male·septicaemia caused by Streptococcus Milleri group pneumonia
Kurt Mellick Andriske, 52, died from septicaemia caused by Streptococcus Milleri pneumonia, with drug toxicity as a contributing factor. He was a complex patient with bipolar disorder, chronic pain, hepatitis B and C, an…
3y · Male·unascertained
A 3-month-old boy died with an unascertained cause after being found unresponsive in his bassinet with a blanket covering his mouth and face. His mother had ongoing heroin use throughout pregnancy and postnatally, concea…
43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …
Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…
58y · Male·Heroin toxicity
58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone)…
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
61y · Female·respiratory failure consistent with end-stage chronic obstructive airways disord…
A 61-year-old woman with chronic obstructive airways disease, liver disease, depression, and alcohol dependence died from respiratory failure. Her general practitioner prescribed a contraindicated combination of central …
57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…
57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…
47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)
Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr Helmy, starting Apri…
55y · Male·Septicaemia due to hydronephrosis and infection
A 55-year-old man with complex medical and social problems died of septicaemia from renal infection. He had a history of cardiac disease requiring anticoagulation, alcohol dependence, depression, and chronic hoarding beh…
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