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VIChome2025-08-07

Finding into death of Emma Louise Terrill

41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity

Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…

general practicepsychiatrysystemtramadol
NSW2024-03-13

Inquest into the death of O A

44y · Male·multiple injuries from fall from cliff

A 44-year-old man with familial Mediterranean fever (FMF) and bipolar affective disorder with drug-induced psychosis died following a fall from a cliff at Vaucluse during a police rescue operation. He had been managing s…

rheumatologyallergy and immunologycommunicationsystemoxycodone
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…

psychiatrygeneral practicediagnosticsystemduloxetine
TAShome2023-10-01

Coroner's Finding: Czerniejewski, Roswitha

66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet

A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couc…

general practicerheumatologysystem
TAShome2022-10-28

Coroner's Finding: O'Shea, Amie Maree

39y · Female·mixed prescription drug and alcohol toxicity (ethanol, tapentadol, tramadol, pro…

Amie Maree O'Shea, aged 39, died from mixed prescription drug and alcohol toxicity on 19-20 May 2019. She consumed excessive alcohol at a social gathering then ingested multiple CNS depressants (tapentadol, tramadol, pro…

pathologytoxicologytapentadol
TAShome2022-08-18

Coroner's Finding: Daw Rodney Keith

63y · Male·acute blood loss due to self-inflicted sharp force incisional wounds of the thro…

A 63-year-old man with multiple chronic conditions including psoriatic arthritis, depression, prostate cancer, and recent dental issues died by self-inflicted sharp force wounds while on approved leave from a mental heal…

psychiatryemergency medicinecodeine
TAShome2021-12-17

Coroner's Finding: Tilley, Jennifer May

58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency

Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …

general practicerheumatologysystemcommunicationpethidine
TAShome2021-10-08

Coroner's Finding: Reaks, Karen Tracey

49y · Female·combined prescription drug intoxication (zopiclone, amitriptyline, periciazine)

Karen Tracey Reaks, aged 49, died from combined prescription drug intoxication involving zopiclone, amitriptyline, and periciazine, with systemic lupus erythematosus as a contributing factor. She ingested medications in …

general practicepsychiatrysystemdelayzopiclone
VICcommunity2021-07-26

Finding into death of Adam Laufer

32y · Male·Multiple injuries sustained in a fall from a height

Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called tr…

psychiatrypsychologysystemcommunication
NSWhospital2019-12-13

Inquest into the death of Lorraine BARNES

85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…

Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…

general medicinerespiratory medicinediagnosticsystemciprofloxacin
QLDhospital2019-12-05

Burrows, Frank Leslie

58y · Male·Haemophagocytic lymphohistiocytosis, due to or as a consequence of T-cell lympho…

Frank Burrows, a 58-year-old male prisoner, died from Haemophagocytic Lymphohistiocytosis (HLH) secondary to T-cell lymphoma. He presented with non-specific symptoms (fever, sweats, diarrhoea) and was initially discharge…

general medicinehaematologydexamethasone
TAShospital2017-05-19

Coroner's Finding: Smith, James Maurice

38y · Male·haemopericardium (pericardial tamponade) due to aortic dissection

James Maurice Smith, 38-year-old male, died from haemopericardium due to aortic dissection. He presented to ED on 9 June 2015 with severe back and abdominal pain, elevated lactate, and neurological symptoms suggesting va…

emergency medicinegeneral surgerydiagnosticcommunicationondansetron
VIChome2015-11-16

Finding into death of Leanne Margaret Patterson

52y · Female·gunshot wound to head

Leanne Patterson, 52, was shot and killed by her husband Neil in a murder-suicide on 5-6 January 2013. She had been sedated with clonazepam (prescribed to her husband) and zolpidem at the time of her death. The death occ…

general practicepain medicinecommunicationsystemclonazepam
WAhospital2015-08-06

Inquest into the Death of Francis Gerald ROBERTS

62y · Male·fatal cardiac arrhythmia secondary to end-stage ischaemic cardiomyopathy

A 62-year-old prisoner with severe ischaemic heart disease, diabetes, and cardiomyopathy died from a fatal cardiac arrhythmia in hospital. He had extensive cardiac history including pacemaker insertion, coronary stents, …

cardiologycardiothoracic surgeryfurosemide
WAhospital2014-08-29

Inquest into the Death of Daniel LAHENGKING

66y · Male·multiple organ failure associated with the combined effects of complications of …

Daniel Lahengking, a 66-year-old Indonesian visiting family in Esperance, was diagnosed with rheumatoid arthritis by locum GP Dr H. and prescribed methotrexate 5-10mg daily, a grossly excessive dose (normal: 7.5-20mg wee…

general practicepharmacydiagnosticmedicationmethotrexate
VIChome2014-06-12

Finding into death of Maree Arthur

45y · Female·Pethidine toxicity

Maree Arthur died from pethidine toxicity at home on 2 February 2008, aged 45. She had complex chronic pain from previous surgeries and motor vehicle injury. Her GP, Dr P., prescribed large quantities of pethidine and ox…

general practicepain medicinemedicationdiagnosticpethidine
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death re…

psychiatryemergency medicinecommunicationsystemdiazepam
SAaged care2014-04-17

Coroner's Finding: WERNER Cynthia Joy

76y · Female·colchicine toxicity

A 76-year-old woman with gout died from colchicine toxicity after being prescribed 500µg three times daily on 9 December 2010 for an acute attack. She developed diarrhoea from 15 December and died on 19 December with a p…

general practicegeriatric medicinemedicationsystemcolchicine
WAhome- 15 May 2014

Inquest into the Death of Helen Barbara MINETT

55y · Female·Multiple drug toxicity in a woman with coronary artery atherosclerosis

A 55-year-old woman with complex medical history including chronic pain, previous multiple abdominal surgeries, gastrointestinal disorders, mental health issues including DID, and suicidal ideation died from multiple dru…

general practicepain medicinediagnosticcommunicationmorphine hydrochloride
VIChospital2010-03-15

Finding into death of Deborah Margaret Ricklefs

29y · Female·Invasive aspergillosis

A 29-year-old registered nurse with systemic lupus erythematosus (SLE) died from invasive aspergillosis. Dr G. prescribed lamotrigine 100 mg daily (double the recommended initial dose of 50 mg) on first consultation with…

addiction medicinegeneral practicemedicationdiagnosticlamotrigine

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