997 results
13y · Female·Multiple injuries due to motor vehicle accident
A 13-year-old Aboriginal girl in residential care absconded with a vehicle after an extended violent altercation with youth workers and died in a high-speed motor vehicle crash. She had extensive trauma history, PTSD, re…
60y · Male·medication overdose
Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…
17y · Female·multiple injuries due to impact by train
A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clin…
11y · Male·Craniocervical trauma
This coronial finding concerns the death of Luke Geoffrey Batty, age 11, killed by his father Gregory Anderson on 12 February 2014 during a cricket practice. Luke was struck with a cricket bat and stabbed with a knife. T…
42y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
A 42-year-old male with a long history of schizophrenia and dissocial personality disorder was released from prison in August 2011 without parole conditions. Despite police and forensic mental health concerns about his r…
26y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
Jason Govan, 26-year-old fitter and turner, was killed in a high-speed head-on collision on the Princes Freeway when the opposing driver, suffering untreated schizophrenia and other mental health conditions, drove the wr…
61y · Male·Complications of cutaneous burns
A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite c…
31y · Male·Hanging
Scott Matthew O'Connor, a 31-year-old male, died by suicide in the Maximum Security Unit of Arthur Gorrie Correctional Centre on 22 January 2013. He had been assessed as high-risk for self-harm and placed on 30-minute ob…
35y · Male·Unascertained, following autopsy. Likely drowning but circumstances undetermined…
A 35-year-old man with chronic alcohol dependence was admitted to the ED with acute alcohol withdrawal and auditory hallucinations. Despite presenting with objective signs of withdrawal (tremor, elevated BP, tachycardia,…
19y · Male·hanging
A 19-year-old male inmate with schizophrenia died by hanging at Long Bay Correctional Centre. Critical failures in mental health care contributed to preventability: despite initial referral in February 2013, he was never…
30y · Female·Fentanyl overdose caused by self-administration of intravenous Fentanyl
Katie Howman, a 30-year-old registered nurse in the Critical Care Ward at Toowoomba Base Hospital, died from an intravenous Fentanyl overdose on 21 December 2013. Autopsy findings of crystalline granulomas in the lungs i…
31y · Male·ligature compression of the neck (hanging)
A 31-year-old man with depression, suicidal ideation, and recent HIV diagnosis presented to emergency department after suicide attempt (carbon monoxide inhalation and diazepam overdose). Despite psychiatrists identifying…
60y · Female·hanging
Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …
34y · Male·Neck compression due to hanging
A 34-year-old man with a history of polysubstance abuse, high alcohol intake, and a recent suicide attempt died by hanging six weeks after being admitted to mental health services. Critical clinical lessons: (1) dual dia…
52y · Male·Multiple injuries and immersion leading to hypoxic brain injury and pneumonia
Male D, aged 52, died from multiple injuries and immersion leading to hypoxic brain injury and pneumonia sustained during an assault. The perpetrator, Y, was a patient with schizo-affective disorder admitted involuntaril…
30y · Male·Heroin toxicity
David D'Angelo, a 30-year-old Aboriginal man with schizophrenia and polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic relapse. His symptoms improved rapidl…
69y · Female·Asphyxiation consistent with hanging
A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…
47y · Male·Toxic effects of phosphine gas
Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…
42y · Male·Gunshot wound to the head
Michael Sweeney, aged 42, died from a self-inflicted gunshot wound to the head on 8 February 2013 while on parole. He attended his ex-partner's home in violation of a Domestic Violence Order to see their infant son. Afte…
46y · Male·asphyxia by hanging
Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After initial hospital assessment and two CAT Team visits, his case was closed on …
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