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QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…

psychiatrygeneral practicecommunicationdocumentationsertraline
VICcommunity2013-01-16

Finding into death of Mark Robert Scott

41y · Male·Effects of Fire

Mark Robert Scott, a 41-year-old man with chronic pain, substance addiction, and recent depressive illness, was admitted to Frankston Hospital on 15 July 2011 following suicidal ideation. During admission, he disclosed t…

psychiatrygeneral practicedelaycommunicationmethadone
VIChome2013

Finding into death of Barabara Lubik

36y · Female·stab injury to neck with transection of left common carotid artery

Barbara Lubik, a 36-year-old Polish immigrant, was fatally stabbed in the neck by her husband Peter Lubik during a domestic dispute on 25 January 2009. The autopsy confirmed the stab wound transected the left common caro…

emergency medicineforensic medicinecommunicationsystem
WAhome2013

Inquest into the Death of Stevens, Malachi Isaac and Stevens, Lochlan James

10y · Male·Unascertainable

Two young children, Malachi (10 months) and Lochlan (2 years), died on 7-8 November 2008 in their mother's home en suite, with cause of death unascertainable. The mother claimed to have blacked out for approximately 10 h…

paediatricsforensic medicinesystemdelay
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

A 39-year-old woman with major depression and Cluster B personality traits died by suicide in Mexico following a pentobarbital overdose on 28 April 2008, resulting in septic shock and nosocomial pneumonia. She had been a…

psychiatryintensive caresystemdelaypentobarbital
VICaged care2012-12-14

Finding into death of Harold Louis

67y · Male·Ischaemic Heart Disease and Coronary Artery Atherosclerosis

Harold Louis, a 67-year-old man with Alzheimer's dementia, ischaemic heart disease, diabetes, and hypertension, was admitted to an aged care facility as 'low care' despite rapidly requiring high-level supervision. Staff …

geriatric medicinecardiologydiagnosticsystem
SAmental health2012-12-13

Coroner's Finding: Jenkinson Jacqueline Mary

46y · Female·mixed drug toxicity

46-year-old woman with bipolar disorder and chronic suicidal ideation died from mixed drug toxicity involving clozapine (prescribed to her roommate), olanzapine, fluoxetine, oxycodone, and diazepam. She disclosed to her …

psychiatrypsychologycommunicationsystemclozapine
VIChospital2012-12-13

Finding into death of William Andrew Poskitt

31y · Male·Injuries sustained in a fall from height

William Poskitt, a 31-year-old man with recently diagnosed HIV and Pneumocystis carinii pneumonia, died by suicide during a 4-day hospital admission. Despite requesting psychiatric assessment three times and displaying c…

infectious diseasespsychiatrycommunicationdiagnostictrimethoprim
VICcommunity2012-11-30

Finding into death of Simon Kirwan

19y · Male·Ruptured aorta post motor vehicle incident

Simon Kirwan, 19, died by motor vehicle collision in circumstances indicating suicide after discharge from involuntary mental health care. He had made three serious suicide attempts within 7 days (overdoses, wrist lacera…

psychiatryemergency medicinediagnosticcommunicationdiazepam
VIC2012-11-16

Finding into death of Rebecca Lazarus

25y · Female·Stab wounds to the chest and abdomen

Rebecca Lazarus, a 25-year-old woman with intellectual disability, was fatally stabbed by her partner Travis Cooke who had chronic treatment-resistant paranoid schizophrenia, was on a Community Treatment Order, and had a…

psychiatryemergency medicinecommunicationsystemclozapine
QLDhome2012-11-14

Galeano, Antonio Carmelo

39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…

Antonio Carmelo Galeano died in police custody on 12 June 2009 after a protracted struggle and multiple taser activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergen…

emergency medicinepsychiatryproceduralcommunicationamphetamine
NSWcommunity2012-11-14

Inquest into the death of Roberto Laudisio CURTI

21y · Male·undetermined causes, in the course of being restrained by members of the NSW Pol…

Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an arm…

psychiatrytoxicologycommunicationsystemLSD
SAmental health2012-10-26

Coroner's Finding: Mitton Paul Laurie

32y · Male·hanging

A 32-year-old man with bipolar disorder and recent suicide attempt died by hanging in a closed psychiatric ward. He was admitted following overdose and suicidal ideation, deemed high-risk, and placed on standard half-hou…

psychiatryemergency medicinesystemcommunicationdiazepam
VIChome2012-10-09

Finding into death of Sue Hui Wang

15y · Female·compression of the neck

Sue Hui Wang, a 15-year-old student, died from compression of the neck between 16-19 September 2010 at her home in Balwyn, Victoria. The coroner found the exact circumstances of death unknown, unable to determine definit…

general practiceforensic medicinecommunicationdelay
VIC2012-09-21

Timothycaseypart1 127708

29y · Male·hanging

Timothy Casey, 29, charged with murder, died by hanging in Port Phillip Prison on 28 March 2008, 12 days after arrival. His death resulted from systemic failures in psychiatric assessment and care. At Melbourne Assessmen…

psychiatrycorrectional healthdiagnosticcommunicationheroin
VIC2012-09-21

Finding into death of Timothy Casey

41y · Male·Hanging

Timothy Casey, a 41-year-old remand prisoner with a history of major depressive disorder and drug/alcohol dependence, died by hanging in Port Phillip Prison in March 2008. The coroner identified multiple system failures:…

psychiatrycorrectional healthdiagnosticcommunication
VICcommunity2012-09-20

Finding into death of Jason Kenneth Chapman

31y · Male·gunshot wounds to chest

Jason Chapman, a 31-year-old man with schizophrenia, was fatally shot by police on 13 October 2004 after behaving erratically and threatening, armed with a knife. The coroner found police acted lawfully in self-defence w…

psychiatrygeneral practicecommunicationsystemantipsychotic medication
QLDcommunity2012-09-14

Isles, MIchael

58y · Male·gunshot wounds

Senior Sergeant Michael James Isles, a 58-year-old Queensland police officer with 34 years of service, disappeared on 23 September 2009. He was the subject of corruption allegations (which proved unfounded), stood down f…

general practicepsychiatrysystemcommunicationfluoxetine
QLDhome2012-09-13

CMC

36y · Female·Excited delirium

A 36-year-old woman died from excited delirium during a physical altercation with her 16-year-old son. She had longstanding alcohol and cannabis use, borderline personality disorder with features of post-traumatic stress…

psychiatryforensic medicinesystemdelayalcohol
SAhospital2012-09-05

Coroner's Finding: KAY Damian

38y · Male·Multiple injuries

Damian Kay, aged 38, died from multiple injuries after jumping from the 16th floor of a hotel on 22 September 2010, with a blood alcohol concentration of 0.71%. The death occurred in the context of recent relationship br…

emergency medicinepsychiatrydiagnosticcommunicationvenlafaxine
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