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WAhospital2012-08-31

Inquest into the Death of Stone

62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …

Pamela Stone, a 62-year-old woman with a complex history of trauma, depression and relationship difficulties, presented to Albany Regional Hospital ED on 26 March 2009 after a violent altercation at home, having been sed…

emergency medicinegeneral practicesystemcommunicationmidazolam
VIChome2012-08-23

Finding into death of Shane Anthony Jarrett

29y · Male·Mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) in a morbidly …

Shane Jarrett, a 29-year-old with schizophrenia and substance abuse history, died from mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) complicated by morbid obesity. During psychiatric hospitalization, …

psychiatrygeneral practicesystemdelayheroin
VICcommunity2012-08-17

Finding into death of Jesse Ross Sangster

28y · Male·Multiple injuries sustained in a motor vehicle collision (driver)

Jesse Sangster, 28, died from injuries sustained in a high-speed motor vehicle collision while intoxicated. He had a 12-year history of bipolar affective disorder with comorbid substance abuse disorder, personality disor…

psychiatryparamedicinesystemdelayalcohol
QLD2012-08-07

Bucknall, David John

41y · Male·Hanging

A 41-year-old male prisoner with a history of depression died by suicide while incarcerated at Wolston Correctional Centre. He was appropriately assessed as low-risk for suicide on arrival and received psychiatric care a…

psychiatrygeneral practicesystemdelaymirtazapine
VIChomePodcast2012-08-06

Finding into death of Margaret Grace McCreddan

59y · Female·Incised wound to right thigh and exsanguination

Mrs Margaret Grace McCreddan, a 59-year-old widow with multiple health conditions including limited mobility and frequent falls, died from exsanguination following an incised wound to her right thigh sustained in a fall …

general practicegeriatric medicinesystemdelaymorphine
VIC2012-07-27

Finding into death of Michael Scott Wyly

41y · Male·hanging

Michael Scott Wyly died by hanging while in custody at Melbourne Assessment Prison on 23 November 2008. He had been remanded following his arrest for alleged murder, with known suicide and self-harm risk history. Clinica…

psychiatrycorrectional healthcommunicationsystem
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

A 49-year-old man with bipolar affective disorder and recurrent depression experienced a relapse while in Tasmania and was referred to a community-based Acute Care Team in Queensland in November 2009. Despite his partner…

psychiatrygeneral practicediagnosticcommunicationsertraline
SAcommunity2012-06-18

Coroner's Finding: JORKOWSKI Natassja Alexandra

19y · Female·asphyxiation

A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…

psychiatrygeneral practicediagnosticcommunicationescitalopram
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…

psychiatryemergency medicinecommunicationsystemvenlafaxine
NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…

psychiatrygeneral practicediagnosticmedicationolanzapine
SAhome2012-05-09

Coroner's Finding: PENNIALL David

24y · Male·neck compression due to hanging

A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…

psychiatrygeneral practicecommunicationdelayvenlafaxine
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-immolate due to distress about power cuts at h…

emergency medicinepsychiatrycommunicationsystem
VIChospital2012-04-12

Finding into death of Gayle Maree Johnson

51y · Female·Complications of anorexia nervosa

A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal …

psychiatryemergency medicinediagnosticcommunication
VICaged care2012-04-04

Finding into death of Alexsandra Birute Volkas

85y · Female·Coronary artery disease and heat exposure

An 85-year-old woman with coronary artery disease was admitted to a low-care supported residential service following bowel surgery. She was frail, hard of hearing, wore spectacles, and showed signs of confusion and distr…

geriatric medicinepsychiatrysystemcommunication
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …

paediatricspsychiatrysystemdelay
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
VICmental health2012-03-13

Finding into death of Matthew Spalding

28y · Male·neck compression subsequent upon hanging

Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …

psychiatryemergency medicinecommunicationsystemaripiprazole
VICmental health2012-03-06

Finding into death of Nikos Karagiannis

26y · Male·Unascertained on an unequivocal medical or pathological basis; likely multifacto…

Nick Karagiannis, a 26-year-old man with schizophrenia, obesity, and significant hepatic steatosis, died unexpectedly at Thomas Embling Hospital's secure psychiatric unit. He was found unresponsive in bed after having no…

psychiatryforensic medicinedelaysystemclozapine
VICcommunity2012-03-01

Finding into death of K

33y · Male·complications from blunt force trauma to head consequent upon being struck by a …

A 33-year-old man with long-standing substance abuse and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm …

psychiatrygeneral practicediagnosticcommunicationmethadone
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…

psychiatryemergency medicinediagnosticmedicationolanzapine
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