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VICmental health2013-08-20

Finding into death of Hassan Yassin

35y · Male·Hanging

Hassen Yassin, a 35-year-old man with schizophrenia, bipolar affective disorder, and PTSD, died by hanging after absconding from an involuntary psychiatric admission. On 10 January 2011, following a clinical review at Br…

psychiatryemergency medicinecommunicationsystemrisperidone
SAhospital2013-08-19

Coroner's Finding: WEEKS Ronald Geoffrey

84y · Male·respiratory failure due to hospital-acquired pneumonia

Ronald Geoffrey Weeks, aged 84, died of respiratory failure due to hospital-acquired pneumonia following a hip fracture sustained in a fall at James Nash House psychiatric facility. He was serving an 8-year sentence for …

geriatric medicineorthopaedic surgerysystemdelay
TAShome2013-08-09

Coroner's Finding: Miss N de-identified

20y · Female·injury caused by hanging

A 20-year-old woman with a long history of eating disorder, obsessive-compulsive behaviours, and adjustment difficulties died by suicide in October 2009. She had received treatment at the Bronte Centre in Melbourne and o…

psychiatrypsychologysystemdelaymethylphenidate
SAhospital2013-07-22

Coroner's Finding: SMITH Trevor John

62y · Male·extensive small cell lung cancer

Trevor John Smith, aged 62, died from extensive small cell lung cancer at Royal Adelaide Hospital on 18 March 2011. He was under Mental Health Act detention when he developed delusions and delirium during his final illne…

oncologycardiothoracic surgerysystemdelaydexamethasone
VIChospital2013-07-11

Finding into death of Stuart Alan Ronning

41y · Male·Hanging

Stuart Alan Ronning, a 41-year-old man with recurrent depressive disorder, alcohol dependency, and previous suicide attempts, presented to Royal Melbourne Hospital emergency department after being found with a noose at a…

psychiatryemergency medicinecommunicationsystemalcohol
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Clinical…

psychiatryintensive caresystemcommunicationrisperidone
SAcommunity2013-06-13

Coroner's Finding: EVANS Bernard Francis

57y · Male·multiple injuries from motor vehicle collision

Bernard Evans, aged 57, died in a motor vehicle collision on 17 January 2011 while evading apprehension under the Victorian Mental Health Act. He had schizoaffective disorder managed with lithium and olanzapine under a C…

psychiatryemergency medicinesystemdelaylithium
SA2013-05-29

Coroner's Finding: RICHARDS Jason Neil

28y · Male·gunshot injury of head, self-inflicted

Jason Neil Richards, aged 28, died from a self-inflicted gunshot wound to the head on or about 21 June 2011 at Coondambo Station, South Australia. He had consumed methamphetamine and amphetamine before embarking on a lon…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
QLD2013-05-27

Hussain, Meqdad

19y · Male·Hanging

Meqdad Hussain, a 19-year-old Afghan asylum seeker, died by hanging in an immigration detention centre (Scherger IDC, Queensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted …

psychiatrygeneral medicinesystemcommunicationmirtazapine
VICcommunity2013-05-27

Finding into death of Nikos Vourdoulidis

46y · Male·Myocardial fibrosis in a man with epilepsy

Nikos Vourdoulidis, a 46-year-old man with intellectual disability and epilepsy, died from myocardial fibrosis in the setting of epilepsy. He collapsed in a shower in November 2008 and was found several hours later. Crit…

general practiceneurologycommunicationsystemcarbamazepine
NThome2013-05-15

Inquest into the death of Michael Chisholm, Aaliyaha Webb and Julian Chisholm

23y · Male·Michael Shane Chisholm: suicide by hanging. Aaliyaha Jane Webb: killing by suffo…

Michael Chisholm, aged 23, suffocated his two young children—Aaliyaha (8) and Julian (4)—at his home, then hanged himself. A critical failure in police procedure was identified: when the mother reported missing children …

psychiatrypaediatricscommunicationsystem
VICcommunity2013-05-08

Finding into death of Marella Johnson

32y · Female·Bilateral haemothoraces with multiple rib fractures and fracture dislocation of …

Marella Johnson, a 32-year-old Aboriginal woman with schizophrenia and schizoaffective disorder, was involuntarily admitted to Alexander Bayne Centre on 17 February 2008 after presenting to Echuca Regional Health intoxic…

psychiatryemergency medicinesystemdelayzuclopenthixol
QLDhome2013-05-03

Thompson, Leanne Melissa

15y · Female·Hypoxic brain injury due to hanging

Leanne Thompson, aged 15, was a severely troubled and vulnerable young woman under a Child Protection Order, living with 28-year-old Alexander O'Sachy, a drug user and violent offender. She had a history of self-harm, dr…

paediatricspsychiatrysystemdelayheroin
VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

Cody Jackson, aged 15, died by asphyxiation from hanging in March 2009. He had a troubled family background with exposure to violence, substance abuse, and criminal activity. Cody was involved with multiple services incl…

psychiatrypsychologysystemdelay
VICmental health2013-03-13

Finding into death of Adam Justin White

35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…

Justin Fraser, a 35-year-old male with first-episode psychosis, died in restraint at Frankston Hospital psychiatric ward on 26 October 2007. He was found attempting suicide by hanging, became agitated and threatening, le…

psychiatryemergency medicinecommunicationproceduralolanzapine
VICpsychiatric hospital ward2013-03-13

Finding into death of Justin John Fraser

35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…

Justin Fraser, a 35-year-old man with first-episode psychosis admitted to Frankston Hospital psychiatric unit, was found attempting suicide by hanging and subsequently became agitated. Security and AMT staff physically r…

psychiatryemergency medicinecommunicationsystemolanzapine
QLDcommunity2013-03-01

Arnold, Vicki; Leahy, Julie-Anne

26y · Female·intentionally inflicted gunshot wounds to the head

This complex triple-inquest into the deaths of two women in 1991 reveals systemic investigative failures and challenges the original murder-suicide finding. Julie-Anne Leahy and Vicki Arnold died from gunshot wounds on 2…

forensic medicinepsychiatrydiagnosticprocedural
VIChospital2013-02-22

Finding into death of Domenico Chiodo

33y · Male·Cardio-respiratory arrest in the setting of prone restraint of an agitated obese…

A 33-year-old man with schizophrenia and a forensic history suffered cardio-respiratory arrest during prone restraint in a busy emergency department after his mental health community treatment order was revoked. He was a…

emergency medicinepsychiatrydiagnosticmedicationolanzapine
VICcommunity2013-01-31

Finding into death of Stuart Beverley

31y · Male·Hanging

A 31-year-old man with borderline personality disorder presented to mental health services after a suicide attempt on 30 March 2005, discharged after psychiatric assessment at Maroondah Hospital ED. Following several cri…

psychiatryemergency medicinecommunicationdelaydiazepam
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

Two psychiatric inpatients (SH, 25-year-old female; AW, 24-year-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite…

psychiatrydiagnosticcommunicationhaloperidol
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