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VIChome2015-01-08

Finding into death of Marzieh Rahimi

33y · Female·Compression of the neck

Ms Marzieh Rahimi, a 33-year-old Afghan refugee, died from compression of the neck following an incident with her husband. She had disclosed a history of extensive physical, verbal, financial and emotional abuse. In the …

psychiatrygynaecologycommunicationsystem
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine
VICcommunity2014-12-22

Finding into death of Dean Alan Carlson Laycock

24y · Male·Strangulation by hanging

Dean Laycock, a 24-year-old man with intellectual disability and psychosis, died by hanging on Christmas Eve 2009, four hours after being informed that his anticipated 4-day Christmas leave from PARC (a psychiatric step-…

psychiatrypsychologycommunicationsystemclozapine
NSWhome2014-12-22

Inquest into the death of Margaret Elizabeth HILLS

60y · Female·undetermined

Margaret Elizabeth Hills, a 60-year-old woman with chronic pain and depression from a work-related spinal injury, disappeared on 2 February 2010 from her home in Katoomba, NSW. Her skeletal remains were discovered nearly…

general practicepsychiatrycommunicationdelay
NSWhospital2014-12-19

Inquest into the death of JX

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

A 32-year-old man with a history of psychotic episodes and depression died by suicide after jumping from a cliff while experiencing an acute psychotic relapse. The case reveals critical failings in mental health crisis r…

psychiatrypsychologycommunicationsystemvenlafaxine
NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…

neurologyneurosurgerycommunicationsystemmadopar
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…

Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…

psychiatrypsychologycommunicationsystemzolpidem
VICmental health2014-12-05

Finding into death of Wieslaw Albin Bernacki

62y · Male·hanging

A 62-year-old man with a long history of severe schizophrenia died by hanging after being granted escorted day leave from a psychiatric inpatient unit. The coroner identified critical failures in communication between ho…

psychiatrycommunicationsystemantipsychotics
VIChome2014-11-28

Finding into death of Chanelle Amy Rae

14y · Female·Compression of the neck in circumstances of hanging

Chanelle Rae was a 14-year-old girl who died by hanging at home following an argument with a school friend online. She had no prior mental health history or significant stressors. The coroner identified a youth suicide c…

psychiatrypublic healthsystemdelay
VIChospital2014-11-26

Finding into death of Daniel Colin McKittrick

25y · Male·Multiple injuries sustained in a fall from a height

Daniel McKittrick, a 25-year-old man with depression, anxiety and recent-onset psychosis, died by suicide on 12 June 2012 after jumping from an eight-storey carpark while Victoria Police negotiators were present. He pres…

psychiatryemergency medicinecommunicationsystemolanzapine
VIChospital2014-11-17

Finding into death of Allan Phipps

76y · Male·exsanguination secondary to pulmonary aortic fistula and thoracic aorta aneurysm…

Allan Phipps was a 76-year-old man with a known thoracic aortic aneurysm and severe depression admitted to Austin Hospital in October 2012 for unstable angina and depression management. His aneurysm, discovered in March …

vascular surgerycardiologysystemdelayquetiapine
VIChome2014-11-11

Finding into death of Tamara Ann Burt

32y · Female·Alcoholic ketoacidosis

Tamara Burt, 32, died of alcoholic ketoacidosis after isolating in her room and drinking excessively. She had bipolar affective disorder, alcohol dependence disorder, and borderline personality disorder traits. Despite o…

psychiatryaddiction medicinesystemcommunicationquetiapine
VIC2014-10-15

Finding into death of Benjamin Elijah Mills

31y · Male·Hanging

Benjamin Mills, a 31-year-old prisoner with depression receiving psychological support, died by hanging in his cell at Barwon Prison. Despite ongoing mental health treatment and plans for transfer to a safer unit, he was…

psychiatrypsychologysystemdelay
VICmental health2014-10-07

Finding into death of Warren Guneratne

25y · Male·consistent with drowning in a man with multiple injuries

Warren Guneratne, a 25-year-old man with paranoid schizophrenia, was admitted involuntarily to the psychiatric unit of Royal Melbourne Hospital on 28 January 2008 after assessment by the Crisis Assessment and Treatment T…

psychiatryemergency medicinecommunicationsystemclozapine
VIC2014-10-07

Finding into death of Darren Carr Hannah

41y · Male·Upper airway obstruction from ingestion of dirt in an intellectually impaired ma…

Darren Hannah, a 41-year-old man with severe intellectual disability, autism, partial blindness and longstanding pica disorder, died from upper airway obstruction after ingesting large quantities of dirt in the backyard …

general practicepsychiatrysystemsupervisiondiazepam
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
VICcommunity2014-08-25

Finding into death of Travis Joseph Hartskeerl

32y · Male·Head and neck trauma (train impact)

Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…

psychiatrygeneral practicecommunicationsystemzuclopenthixol decanoate
VICcommunity2014-08-25

Finding into death of William Patrick Slater

67y · Male·Multiple injuries from motor vehicle collision

William Patrick Slater, aged 67, was killed in a motor vehicle collision caused by Kane Miller, a 24-year-old driver with schizophrenia who was on prescribed medication and had tested positive for morphine, cannabis, mid…

forensic medicinepsychiatrysystemdelaymorphine
NSWhospital2014-08-22

Inquest into the death of Alana GOLDSMITH

21y · Female·Multiple injuries sustained from being struck by a train; death by suicide while…

Alana Goldsmith, a 21-year-old woman with long-standing anorexia nervosa, died by suicide on 22 July 2011 after stepping in front of a train at Summer Hill Railway Station. She was admitted to Wesley Eating Disorder Clin…

psychiatrygeneral practicecommunicationsystemolanzapine
VICcommunity2014-08-13

Finding into death of Frederick Russell Morgan

48y · Male·Unknown causes (presumed suicide by drowning)

Frederick Russell Morgan, a 48-year-old stockbroker, disappeared on 15 July 1971 from Mt Martha beach. He had experienced severe depression triggered by business financial crises, tax assessment concerns, and his father'…

psychiatrypsychologydiagnosticdelayantidepressant medication
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