ABSTRACT Intersections of human and animal lives regarding human suicide are just beginning to be explored. Given that the investigation of human suicide poses major ethical concerns, seeking out publicly accessible information in the first instance is important. Public media reports of suicide are limited in Australia (as in many countries) by voluntary adherence to recommendations that suicides should only be reported if of substantial public significance. While macro data on suicide in Australia is available, the presence or role of animals in these human scenarios is not reported. However, some detailed coroners’ investigations of suicide scenarios are available via state coroner websites. Publicly available reports between 2016 and 2020 from all Australian states and territories were manually searched for mention of pets/animals using a range of keywords in scenarios investigated as suicide. Fewer than 30 reports were identified. A critical discourse analysis was undertaken of the mentions of pets/animals in these reports. This included theming of core qualitative data. The overarching theme identified was the insignificance of pets within coroners’ reports of suicide. Four subthemes were identified: pets as beloved; potential aggressors; incidental to reporting; and enmeshed in human domestic violence. Despite the increasing inclusion of pets within definitions of kin, nonhuman family members are virtually invisible in Australian coronial discourses investigating possible suicides. Even when pets were noted by informants as being extremely important in the life of the deceased, there was no evidence of this relationship being seen as part of the legitimate enquiry in terms of causation or future preventative strategies. While current data are limited, given emerging research on the role of pets in human suicidality it is possible that this humancentric bias may be overlooking potentially protective and preventive approaches to suicide. It is certainly overlooking animal victims of these tragedies.

Management of deaths in temporal relationship to COVID-19 immunisation in NSW

Reviewed by: The Uncommon Case of Daniel Brown: How a White Police Officer Was Convicted of Killing a Black Citizen, Baltimore, 1875 by Gordon H. Shufelt Lauren N. Henley The Uncommon Case of Daniel Brown: How a White Police Officer Was Convicted of Killing a Black Citizen, Baltimore, 1875. By Gordon H. Shufelt. True Crime History. ( Kent, Ohio: Kent State University Press, 2021. Pp. xii, 171. $24.95, ISBN 978-1-60635-412-4.) In The Uncommon Case of Daniel Brown: How a White Police Officer Was Convicted of Killing a Black Citizen, Baltimore, 1875, Gordon H. Shufelt examines the specific circumstances that led to Patrick McDonald, an Irish immigrant, being convicted of manslaughter in the death of Black Marylander Daniel Brown in post–Civil War Baltimore. In so doing, Shufelt offers a methodological framework "in which to examine the social, political, and cultural characteristics that [End Page 180] define the quality of justice in cases of police violence" (p. 6). This approach necessarily draws on what makes this case unique as opposed to representative, ultimately concluding that myriad factors at this particular place and time allowed Daniel Brown's death to be prosecuted in the manner Shufelt outlines. The Uncommon Case of Daniel Brown is organized around biographical sketches of the victim and perpetrator, with chapters on the role of the coroner's office, the politics of policing, and the trial itself. It ends with commentary on the post-trial proceedings and on the thread between this nineteenth-century case and the modern Black Lives Matter movement. The biographical chapters, "The Black Man in the Doorway" and "The Irish Policeman on the Doorstep," are solid examples of culling together individual people's lives from fragmentary evidence. Relying on census records, newspaper articles, city directories, published primary sources, and secondary literature, these chapters attempt to characterize Daniel Brown and Patrick McDonald. By the end of the first chapter, Brown is portrayed as a self-assured, literate homeowner who was "inclined to be outspoken about his rights" (p. 24). McDonald becomes an Irish immigrant who "was no stranger to street fighting" and "more willing than most men" to use "fists, clubs, and pistols" aggressively (p. 39). While these depictions are no doubt oversimplified, they provide texture and specificity to that fateful midsummer night in 1875. After convincingly arguing for the unique cultural setting of postwar Baltimore, where residential segregation was not as complete as in the Deep South and where Irish immigrants and Black freedpeople changed the city's demographics in a relatively short span of time, Shufelt turns toward another unique feature of nineteenth-century Maryland: discretionary coroner's juries. By reasoning that a lack of precedents and formalization in the state's coroner positions shaped how cases were adjudicated, Shufelt persuasively demonstrates the importance of coroner's juries in expressing a "community's social and political norms" (p. 54). This focus on the power of this particular component of pretrial proceedings—the coroners' inquests—contributes to the growing literature on race and crime in the late nineteenth and early twentieth centuries. Shufelt successfully demonstrates how pretrial records can provide robust insights into how criminality was adjudicated in the Jim Crow era. At times, Shufelt's balance between the specifics of the Daniel Brown case with the broader Baltimorean context seems disproportionate. Chapters 4 and 5 are about perceptions of the police in terms of racial and political biases, respectively. The former chapter's reliance on white newspapers, without explicitly mentioning the Black press, reads like an incomplete account of how Black citizens responded to the city's police. Chapter 5's deep dive into the history of policing and corrupt politics throughout the mid-nineteenth century is a fascinating political history of Baltimore but does not make a strong case for such in-depth background information related to the Daniel Brown case specifically. Given contemporary protests of the killings of Black men and women at the hands of the police, Shufelt's study provides a useful historical lens to understand how the convergence of nuanced factors makes each case unique. [End Page 181] Lauren N. Henley University of Richmond Copyright © 2022 The Southern Historical Association

Interview with the State Coroner conducted on 12 August 2021 via a video link to the Coroners Court of Victoria in Melbourne.

A detailed neuropathological assessment of a Western Australian case of Balamuthia mandrillaris amoebic encephalitis

Bereaved parents' experiences of the police in the paediatric intensive care unit

In 2016, the Office of the State Coroner of New South Wales released its report into the death of an Australian woman, Sheila Drysdale, who had died from complications of...

A psychiatrist working in one of the world’s worst suicide hotspots has said that identifying people at risk is like “capturing lightning in a jar.” Murray Chapman is clinical director of the Kimberley Mental Health and Drug Service, which is based in Broome in remote northwestern Australia, more than 2000 km from Perth. Indigenous communities in the region are in the grip of a suicide crisis. In March a 10 year old indigenous girl is believed to have hanged herself, in one of more than 20 recent suspected suicide cases being investigated by the Western Australia state coroner. Chapman, who is originally from the United Kingdom and has spent the past 14 years in the Kimberley region, said, “We know we [mental health services] can’t stop it on our own. We have a certain role. We save one or two, but we are standing at the bottom of a cliff. Trying to …

In the first half of 2016, two very different but significant inquests - on opposite sides of the world - entered their final stages. In Sydney, Australia, the inquest into the deaths resulting from the 17-hour siege at the Lindt caf in December 2014 has been undergoing its final segment of public hearings before State Coroner Michael Barnes, after beginning in January 2015. The inquest has scrutinised the siege and events around it, including key questions such as why the gunman was on bail, what the authorities knew about him, and police decision-making in response to the siege. Meanwhile, on 26 April 2016, in Warrington, north-west England, following a two-year hearing beginning in March 2014, the jury emerged after two weeks of deliberation to deliver the conclusion of 'unlawful killing' in the Hillsborough Inquests before the Right Honourable Sir John Goldring, sitting as Assistant Coroner.

Child protection systems in Australia are struggling to cope with the growing number of children requiring out-of-home care because of abuse or neglect occurring within families. Professionals and governments are grappling with the alternative care options that are available in an attempt to improve children’s health, education and emotional development. Research demonstrates that children suffer if they are exposed to multiple placements throughout childhood and this leads some to believe that the permanency of adoption would better serve the needs of children from broken families. This article considers the recent proposal by the South Australian State Coroner to expand the role of adoption as a child protection response, noting that New South Wales introduced such a model in 2014. It also examines international approaches in this area as well as the findings of studies into foster care and adoption. By drawing together the knowledge gained from different policy and practice approaches to out-of-home care, this article argues that introducing a blanket approach favouring adoption is not an appropriate option. It concludes that the only model likely to achieve the best outcomes for children is one involving individual responses to every child.

To determine the incidence and clinical features of laparoscopic gynaecological deaths in Australia. Gynaecological laparoscopic mortality data were obtained from the National Coronial Information Systems (NCIS) and Australian State Coroners Courts, for the period July 1 2000 to December 31 2012. Eighteen deaths were identified, providing a mortality rate of approximately 1 per 70,000 laparoscopic procedures. The commonest cause of death was from bowel perforation, most of which were unrecognised during the operation. Gynaecologists should be trained to recognise and manage the rare event of laparoscopic perforation of a viscus or a blood vessel.

According to the Centers for Disease Control and Prevention (CDC), more than 36,000 individuals were victims of a fatal drug overdose in 2008.1 The majority of these deaths were related to prescription drug abuse, most frequently opioid analgesics. Multiple factors have contributed to the severity of opioid abuse and misuse in the United States, including a substantial increase in the number of opioid prescriptions dispensed by retail pharmacists (from an estimated 76 million in 1991 to over 200 million from 2009 to 2013), more social acceptability for administering medications for different purposes, and an increase in marketing of medications.2 As part of a multifaceted effort to curb the increase in prescription drug abuse, the majority of states have implemented prescription drug monitoring programs (PDMPs). These programs “collect, monitor, and analyze electronically transmitted prescribing and dispensing data submitted by pharmacies and dispensing practitioners.”3 The overarching goal of this data collection and analysis is to support efforts related to enforcement, education, research, and abuse prevention. Although almost all states have a PDMP (excluding Missouri), state laws and rules governing these programs vary significantly. It is important for pharmacists and prescribers to be familiar with their state laws. A comprehensive listing of all state PDMP Web sites may be found at: http://www.pdmpassist.org/content/state-pdmp-websites.4 In addition, the National Alliance for Model State Drug Laws maintains an up-to-date site on the status of PDMP legislation at: http://www.namsdl.org/prescription-monitoring-programs.cfm.5 Administration of PDMP programs is performed by the individual state; the federal Drug Enforcement Agency (DEA) is not involved with the administration of any state PDMP.6 The state agency responsible for PDMP oversight varies, with boards of pharmacy and departments of health being the most common state agencies involved in PDMP administration.7 Most states collect and analyze data on use of schedule II to V controlled substances; however, some states only collect data on schedule II to IV substances, and one state (Pennsylvania) monitors the use of schedule II medications only. Access to information within the PDMP is determined by state law and is generally limited. Prescribers and pharmacists are allowed to obtain reports on patients under their direct care in most states. Some states also provide access to PDMP information to law enforcement, licensing and regulatory boards, state Medicaid programs, medical examiners or coroners, and certain research organizations. Although PDMP implementation has resulted in progress in combating drug diversion and abuse, there are still deficiencies that need to be addressed. Shepherd listed these PDMP deficiencies as inadequate data collection, ineffective utilization of data, insufficient interstate data sharing, and underuse of certain information by law enforcement.7 Table 1 provides comments on the deficiencies present in each category. Table 1. Deficiencies of prescription drug monitoring programs7 In conclusion, pharmacists need to be aware of state laws and rules regarding PDMPs. These laws and rules vary significantly from state to state. Although PDMPs have helped to combat prescription drug abuse and diversion, there are still deficiencies in these systems that need to be addressed.

Having served as a board-certified forensic pathologist in the southern tier of New York for over 23 years, the author has received cases from over a dozen rural New York State coroner counties. While some coroners are physicians, none of them is a pathologist, and most are not in the medical profession. Some are appointed by their county legislature, whereas others are elected. Levels of coroner training and experience in death investigation, terms of office, multiple coroners per county, and turnover of coroner staff are all challenges for the consultant forensic pathologist. Functioning as an autonomous independent contractor, a forensic pathologist can bring standardization, medical knowledge, and reliability to the determination of cause, mechanism, and manner of death, even when resources are less than optimal. As fewer hospital pathologists perform autopsies, and as community hospitals opt to close their morgues entirely, regional centers emerge to absorb the workload. In such a setting, the forensic pathologist must establish a working relationship with an institution such as a regional hospital to support an adequate physical plant for an autopsy service. Until such time as adequate manpower and financial resources are available, a coroner-based death investigation system is still a necessary complement to the medical examiner system in New York State. There are both drawbacks and advantages to such a practice for the independent forensic pathologist. Yet the citizens of this area of New York State are served by a death investigation system that is functional and meets basic needs.

Criticism regarding the objectivity of photographic evidence when used during judicial hearings is beginning to emerge within the forensic and scientific literature. The second coronial inquest into the death of Romuald Todd Zak is a case that highlights the dangers of photographic evidence when inappropriately used to support forensic evidence. The Western Australian State Coroner, Alastair Hope, was highly critical of evidence presented by forensic experts during the second inquest. This article examines Hope's findings and discusses issues associated with the interpretation and representation of photographic evidence.

The objective of this study was to determine whether farming suicides increased in Victoria during the prolonged drought in south eastern Australia and gain an understanding of Victorian farming suicides during the period. Intentional self-harm deaths of farmers and primary producers notified to the Victorian State Coroner from 2001 to 2007 were examined to identify characteristics and determine whether the annual number of farming suicides increased. Farming suicides accounted for just over 3% of Victorian suicides. The total number of farming suicides was 110 for the period and ranged between 11 and 19 deaths per year, rising and falling inconsistently from year to year. Males accounted for nearly 95% of farming suicides, with firearms and hanging the most frequently used methods, and most deaths occurring between 30 and 59 years of age. The small number of relevant cases and fluctuations in the annual number of deaths provides no evidence of a pattern of increasing farming suicides during the drought years, when there was approximately one suicide every 3 weeks. Given the elevated suicide risk in male farmers and association with multiple psychosocial and environmental factors, it cannot be concluded, however, that suicide risk itself did not increase during this period of heightened uncertainty and stress. Drought should not be dismissed among the many risk factors, and it is possible that increased mental health awareness and community support programs targeting drought-affected areas contributed to improved management of stress and suicide risk in regional and rural Victoria over the past decade.

Priest v West (in his capacity as Deputy State Coroner of Victoria and Another)

In December 2010, the Full Court of the South Australian Supreme Court dismissed an application for judicial review of a decision of the State Coroner that there was jurisdiction to conduct an inquest into the death of a newborn infant. The basis for the application was that there was no “reportable death”—as required under the Coroner’s Act 2003 (SA)—because the infant did not satisfy the “bornalive” rule. It was argued that the infant was not “born alive” and, thus, in turn, there was no “death of a person” as required by s 21 of the Act. The Court determined that indeed the child was born alive and that the death fell within the jurisdiction of the Coroner’s Court. Special Leave to Appeal was denied by the High Court in June 2011 on the basis that the question, as argued by the appellant, did not raise a question of general principle and that the conclusion reached by the Supreme Court did not extend the concept of “born alive” (Barrett v Coroner’s Court of South Australia [2011] HCA Trans 165). The coronial inquest is yet to be held. The facts of the case arose out of an unremarkable pregnancy that progressed naturally to an equally unremarkable labour. The birth was a planned home birth, and the plaintiff, who was an experienced midwife, was in attendance. Unfortunately, the infant became trapped in the birth canal and was not fully separated from the mother for a full 15 minutes or more. During the time in the birth canal, the infant was deprived of oxygen and was, it is believed, asphyxiated. After separation from her mother, at no time did the infant demonstrate any of the traditional “signs of life” (crying, breathing, or moving). The attending ambulance crew placed a heart monitor on the infant and observed “pulseless electrical activity” (PEA). The ambulance crew continued to try resuscitation. Eventually, PEA ceased and the infant was declared dead. It was established that the infant died from significant hypoxia (deprivation of oxygen), and the coroner determined that there was jurisdiction for a coronial enquiry. The Court examined the jurisdiction of the Coroner’s Court; of particular relevance to this decisionwas s 21 of the Act, which provides, inter alia, that the Court will Bioethical Inquiry (2011) 8:323–327 DOI 10.1007/s11673-011-9324-0

Piatkov I, Jones T, Van Vuuren RJ. Suicide cases and venlafaxine.Objective: Our aim was to establish whether the presence or absence of fully functioning cytochrome P450 2D6, 2C19 and 2C9 genetic alleles was associated with suicide in patients receiving venlafaxine treatment.Method: Authorisation from the NSW State Coroner to perform post-mortem genetic testing was obtained for 11 samples from deceased persons who committed suicide during treatment with venlafaxine (VENADR study).Results: All patients, but one, have at least one copy of the loss-of-function, altered or decreased cytochrome P450 enzyme activity allele. Four patients' results reveal loss-of-function genotypes, while all others were found to have diminished enzyme activity polymorphisms. Seven patients had multiple altered function polymorphisms, which included CYP2D6, CYP2C19 or CYP2C9.Conclusion: Our preliminary limited data show that neurotoxicity development, which manifests as suicide while on venlafaxine treatment, probably correlates with a higher prevalence of gene copies of altered functioning cytochrome P450 genetic polymorphisms.

BackgroundOut-of-hospital cardiopulmonary arrest (OHA) is an international health issue. There is an urgent need to better understand the key factors that affect OHA survival. Epidemiological surveillance is the first step towards scientific understanding of the problem. This study looks at the profiles of patients who suffered an OHA.MethodologyIn this retrospective study, the medical records of all patients who died upon arrival at Tan Tock Seng Hospital, Emergency Department (TTSH ED) between 1st January 2009 and 31st December 2009 were reviewed. The outcomes include patient demographics, pre-hospital management and the cause of death.ResultsWithin the study period, there were a total of 275 OHA, 5 (1.8%) traumatic and 270 (98.2%) non-traumatic cases. Emergency Medical Service (EMS) conveyed 247 (91.5%) of OHA and 23 (8.5%) arrived by self-transport. The incidence of non-traumatic OHA was 14 per 10,000 ED attendees, predominantly male (72.2%). Male were significantly younger than female (63 vs 70 years, p = 0.002). The commonest initial cardiac arrhythmia recorded on scene by paramedics was asystole (54.1%), pulseless electrical activity (34.8%) and ventricular fibrillation (11.1%). One hundred sixty-one (59.6%) patients collapsed during the day (0600 – 1759 hours). Patients found in ventricular fibrillation on scene peaked in the morning (1020hours). All OHA were started on cardiopulmonary resuscitation, intubated with laryngeal airway mask, given intravenous adrenaline, and all ventricular fibrillation was electrically defibrillated en-route by the paramedics. Despite continued resuscitative efforts in the ED, all remained in asystole. The State Coroner reviewed 266 (96.7%) OHAs, of which, 96 (36%) were subjected to post mortem. Among patients with asystole at scene, acute coronary syndrome (55.2%), hypertensive heart disease (13%) and bronchopneumonia (5.2%) were the three commonest cause of death. The commonest cause of death for ventricular fibrillation at scene was acute coronary syndrome (76.7%), of which 10 (43.5%) had no pre-existing medical conditions.ConclusionIn our study population, majority of patients had asystole as their presenting arrhythmia at scene. OHA with ventricular fibrillation demonstrated significant circadian differences and the underlying cause of death was acute coronary syndrome. This knowledge will allow EMS to devise future strategies that have the greatest potential to improve survival outcomes.

The increasing use of 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") and tendency of users to combine MDMA with pharmaceutical agents (especially serotonergic medication) warrants a thorough understanding of MDMA's toxicity profile and potential for drug interactions. This study examined the involvement of MDMA and concurrently administered pharmaceutical drugs in cases reported to the Victorian State Coroner. The National Coroners Information System was used to conduct a comprehensive search and examination of all closed cases between 2002 and 2008 where MDMA was detected. Pathology, toxicology, and Coroners' findings were considered in all cases. In all, 106 fatalities were identified, of which 43 (41%) cases involved the concomitant use of MDMA with other drugs, including pharmaceuticals that were likely to result in an adverse drug reaction or varying risks (4 high-risk cases involved moclobemide and MDMA, in addition to 10 moderate-risk cases, and 5 minor-risk cases). These findings highlight the importance of recognizing and publicizing potential drug interactions between MDMA and pharmaceutical preparations that may result in lethal toxicity, in particular serotonin toxicity.