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SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …

psychiatrycorrectional healthsystemcommunicationmethamphetamine
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

Declan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stan…

psychiatrycorrectional healthsystemdelaylithium
WAhospital2012

Inquest into the Death of Keogh

38y · Female·Pulmonary Thromboembolism

Kellie Anne Keogh, 38, died from pulmonary thromboembolism on 10 November 2008 after complex pancreatic surgery. She had nephrotic syndrome with decreased anti-thrombin III levels, initially presenting with suspected DVT…

general surgeryintensive carecommunicationdelaywarfarin
SAcommunity2011-12-22

Coroner's Finding: HYNES Simon Christopher

41y · Male·acute neck compression due to hanging

Simon Christopher Hynes, aged 41, died by hanging between 7 June and 5 July 2007, shortly after discharge from hospital on leave of absence under a Mental Health Act continuing detention order. He had a 20-year history o…

psychiatryforensic medicinedelaycommunication
NSW2011-12-19

Villawoodfindings redacted

Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)

Three immigration detainees died by suicide at Villawood Detention Centre in Sydney within three months in 2010. Josefa Rauluni (Fijian) jumped from a balcony on 20 September after being informed of imminent removal desp…

psychiatrygeneral medicinediagnosticcommunicationmirtazapine
QLD2011-12-09

Inglis, Tracey Lee

37y · Female·exsanguination from incised wounds to right wrist and elbow

Tracey Inglis, a 37-year-old woman with chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial R…

psychiatrygeneral practicediagnosticcommunicationparacetamol/codeine
SAhospital2011-11-03

Coroner's Finding: BALLARD Margaret Dawn

76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction …

A 76-year-old woman with Alzheimer's dementia and psychiatric illness collapsed on 1 January 2009 and was assessed in the Emergency Department. Dr B. diagnosed vasovagal syncope with gastroenteritis based on the patient'…

emergency medicinepsychiatrydiagnosticcommunicationsodium valproate
WAcommunity2011-10-21

Inquest into the Death of Balgo

Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…

This coronial inquiry examined five deaths in Balgo Aboriginal Community over a 24-month period: four suicides by hanging and one death from volatile substance abuse. The suicide rate in Balgo was more than 100 times the…

general practicepsychiatrysystemdelaypetrol
NSWhome2011-10-14

Coroner's Finding: Adam Quddus Salter

36y · Male·Gunshot wound to chest

Adam Quddus Salter, aged 36, experienced acute psychiatric decompensation on 18 November 2009 while living at his family home. After stabbing himself multiple times, paramedics and police were called. While paramedics tr…

general practicepsychiatrydiagnosticsystemefexor xr
QLD2011-10-14

Death of a prisoner

34y · Male·Asphyxia consistent with plastic bag asphyxia

A 34-year-old male in pre-trial custody at Arthur Gorrie Correctional Centre died by asphyxiation using a plastic bag on 3 September 2008. He had a psychiatric history with prior suicide attempts and was on olanzapine. H…

psychiatrycorrectional healthsystemdelayolanzapine
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

Amanda Kennedy, a 26-year-old woman with a history of trauma, substance abuse, depression, and multiple suicide attempts, died by hanging in the Northern Psychiatry Unit on 24 June 2010 while under involuntary psychiatri…

psychiatryemergency medicinecommunicationsystemquetiapine
QLDhome2011-10-10

JTN and AJN

Unknown·Incineration from a house fire. The children were subject to poor supervision fr…

Two young children (aged 3 and 2 years) perished in a house fire in 2008 while under the supervision of their grandmother, who had been previously determined by the Department of Child Safety to be inappropriate for this…

paediatricspsychiatrysystemdelay
SAhospital2011-10-06

Coroner's Finding: BROWN Kunmanara

18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hangi…

An 18-year-old Aboriginal man died from hypoxic brain injury following cardiac arrest from hanging. He had a chronic petrol-sniffing habit and was acutely intoxicated on petrol when he hanged himself after a police incid…

emergency medicineintensive carecommunicationsystempetrol
SAhospital2011-09-23

Coroner's Finding: BLYTHE Dorothy Josephine

81y · Female·ischaemic bowel

An 81-year-old woman with longstanding depression and multiple comorbidities fell and fractured her humerus in March 2009. During rehabilitation, she became increasingly depressed and self-neglectful, refusing food and c…

psychiatrygeneral surgerydiagnosticdelay
VIChome2011-09-13

Finding into death of Rosa Sinapi

47y · Female·risperidone toxicity

Rosa Sinapi, a 47-year-old woman with delusional disorder, died from risperidone toxicity after ingesting an overdose of her antipsychotic medication. She had self-escalated her risperidone dose from 3mg to 6mg daily wit…

psychiatrygeneral practicesystemdelayrisperidone
SAmental health2011-08-26

Coroner's Finding: REX Michael David

41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)

Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) while detained in Ward 5H of the Margaret Tobin Centre ps…

psychiatrypharmacysystemdelaymethadone
VIChospital2011-08-16

Finding into death of Lisa Irene Sharp

34y · Female·Hanging with combined effects of ethanol and benzodiazepines

Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a cour…

psychiatryemergency medicinediagnosticcommunicationdiazepam
VIChome2011-08-15

Finding into death of James Martin Todd

41y · Male·Neck compression subsequent upon hanging

A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…

general practicepsychiatrysystemdelayparoxetine
NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

A 25-year-old university student with a complex history of schizoaffective disorder and substance misuse died by hanging during family leave from a mental health ward. He had been stable on depot antipsychotic medication…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
NSW2011-07-07

Coroner's Finding: Brian Gerard Dunningham

42y · Male·Hanging (self-inflicted) while suffering from serious mental illness

Brian Dunningham, aged 42, died by hanging at Bathurst Correctional Complex (9–10 September 2009) while in custody. He had serious mental illness (psychosis, depression) requiring antipsychotic and antidepressant medicat…

psychiatrycorrectional healthdiagnosticmedicationmirtazapine
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