Deceased
SK
Demographics
25y, male
Coroner
Deputy State Coroner Paresa Spanos
Date of death
2022-01-30
Finding date
2024-12-02
Cause of death
Gunshot injury to the head
AI-generated summary
SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannabis, benzodiazepines and other drugs. SK had engaged with mental health services following a suicide attempt in June 2021 and was referred to substance abuse treatment services (STAR), which he initially engaged with but subsequently disengaged after several sessions. Mental health treatment was deemed appropriate and reasonable by the CPU. However, clinical lessons include: the importance of integrated mental health and substance abuse services (SK had to navigate separate systems), the challenge of managing patients with polysubstance dependence who disengage from treatment without clear reason, and the need for comprehensive safety planning regarding access to weapons in high-risk individuals. The coroner noted that substance-induced impairment of judgment and coordination significantly increased risk when handling firearms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
47y · Male·Acute myocardial infarction due to thrombotic occlusion of the right coronary ar…
Nick Panagiotopoulos, a 47-year-old man, suffered a fatal acute myocardial infarction (heart attack) on 16 October 2021 at home in Preston, Victoria. His family made five calls to Triple Zero (000) requesting emergency a…
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.