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QLDcommunity2015-06-09

JE and JJ, two 16 year old boys

16y · Male·Hanging (ligature compression of neck)

Two Indigenous young men, JE (16 years) and JJ (16 years), both died by hanging within four months during a suicide cluster in Mackay, Queensland in 2008. JE's death was impulsive, occurring after paint sniffing and alco…

psychiatryemergency medicinediagnosticcommunicationalcohol
VICaged care2015-05-14

Finding into death of Philip John Roberts Hewitt

64y · Male·Acute traumatic subarachnoid haemorrhage secondary to single penetrating injury …

A 64-year-old man with schizophrenia was fatally stabbed in the eye by his roommate at a supported residential services facility. The roommate had a 12-year history of making specific threats to kill, including eye-pokin…

psychiatrygeneral practicediagnosticcommunicationolanzapine
VIChome2015-05-13

Finding into death of Dan Lin

21y · Female·Blunt force trauma to the head

Dan Lin, a 21-year-old woman, was killed by her mother-in-law in a violent domestic assault. This death occurred within the context of family violence, with prior documented physical assaults by the perpetrator in July 2…

forensic medicinegeneral practicecommunicationsystem
VICmental health2015-05-07

Finding into death of Narelle Ena Clancy

49y · Female·Hanging

Narelle Clancy, aged 49, absconded from a psychiatric ward within hours of being placed on involuntary status and died by hanging. She had a long history of depression and suicidal ideation following her daughter's suici…

psychiatrycommunicationsystemolanzapine
VICcommunity2015-05-07

Finding into death of Krisinda Carmen Smart

15y · Female·toxicity to heroin

Krisinda Carmen Smart, aged 15, died from heroin toxicity on 20 January 2008. She was a child in care of the Department of Human Services subject to a Custody to Secretary Order. In the days before her death, there were …

paediatricsemergency medicinediagnosticsystemheroin
SA2015-05-06

Coroner's Finding: BLUNDEN Shane Rene

18y · Male·acute neck compression due to hanging

Shane Blunden, aged 18, died by hanging in Yatala Labour Prison on 19 September 2011. He was a remanded prisoner with an extensive history of self-harm, including cutting, swallowing batteries and razors, and a previous …

correctional healthemergency medicinediagnosticcommunicationcannabis
VIChospital2015-04-23

Finding into death of Craig Ronald McMillan

37y · Male·Unascertained (death in custody)

Craig McMillan, 37-year-old male with chronic schizophrenia, died of undetermined cause (death in custody) after being transported by police divisional van to hospital. Despite documented tachycardia from Risperidone, th…

psychiatryemergency medicinecommunicationsystemrisperidone
NTprison2015-04-13

Inquest into the death of Raymond McDonald

49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…

Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…

cardiologygeneral practicediagnosticdelay
VIChome2015-04-13

Finding into death of Athiel Deng

59y · Female·head injury

Ms Athiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in…

psychiatryemergency medicinesystemdelaycannabis
VIChospital2015-04-02

Finding into death of Joseph Mallia

53y · Male·metastatic pancreatic cancer

Joseph Mallia, a 53-year-old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possib…

general practiceradiologydelaysystem
VIChospital2015-04-02

Finding into death of Maria Teresa Nigro

53y · Female·hanging

Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…

psychiatrycommunicationsystemsertraline
VICaged care2015-03-26

Finding into death of Chang Ying Xu

72y · Female·Hanging

Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…

general practicegeriatric medicinediagnosticcommunicationbuprenorphine
VIChome2015-03-18

Finding into death of Christopher John Dokos

45y · Male·Complications of heat stroke in a man with schizophrenia

Christopher Dokos, a 45-year-old man with schizophrenia on Clozapine treatment, died during the extraordinary January 2014 Victorian heatwave. He had multiple heat-vulnerability risk factors: mental illness, antipsychoti…

psychiatrygeneral practicesystemdelayclozapine
VIChome2015-03-18

Finding into death of Katrina Ruth Baron

50y · Female·Complications of heat stroke in a woman with schizophrenia

A 50-year-old woman with long-standing schizophrenia treated with clozapine died from complications of heat stroke during an unprecedented Victorian heatwave. She and her partner were not contacted by mental health servi…

psychiatrygeneral practicesystemcommunicationclozapine
QLDhospital2015-03-13

Cuttler, Melina Maree

29y · Female·Multiple injuries due to fall from height

A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. Multiple systemic and clinical failures delayed appropriate …

emergency medicinepsychiatrydiagnosticcommunication
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

A 48-year-old man with schizoaffective disorder, poorly controlled diabetes, sleep apnoea, obesity and cardiomegaly died unexpectedly at a rural hospital following acute psychotic agitation. He had absconded from a menta…

psychiatrygeneral practicesystemdelayhaloperidol
VICcommunity2015-03-03

Finding into death of Jahit Elliott Alieff

27y · Male·hanging

A 27-year-old man with schizo-affective disorder died by hanging on 22 April 2009 while on a Community Treatment Order (CTO). He had been discharged from psychiatric hospitalization in December 2008 and managed by an out…

psychiatrycommunicationsystemrisperidone
WAhospital2015-02-26

Inquest into the Death of Peta Susan DOIG

58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury

A 58-year-old woman with autism and severe intellectual disability died from pneumonia and cardiac failure complicated by hypoxic brain injury following cardiac arrest. She had been institutionalised at Graylands Hospita…

psychiatryintensive carediagnosticdelayazithromycin
WAmental health2015-02-26

Inquest into the Death of Tracy Margaret MARSHALL

47y · Female·Ligature compression of the neck (suicide by hanging)

Tracy Margaret Marshall, a 47-year-old woman admitted to Nickol Bay Hospital as a voluntary patient due to deteriorating mental state and suicidal ideation, left the hospital on 21 February 2011. She drove to a remote lo…

psychiatrysystemdelay
NSWcommunity2015-02-20

Inquest into the disappearance and suspected death of Margery Joyce TAYLOR

50y · Female·unascertained

Margery Joyce Taylor, aged 50, disappeared on 7 September 1978 from Warren, NSW. She had a long history of bipolar disorder and depression with prior psychiatric hospitalisations. Two months before disappearance, she was…

psychiatrygeneral practicesystemdelay
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