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QLDhospital2011-06-24

(C) a 15 month old child

1y · Male·Complication of burns and trauma to the mesenteric artery

A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
NSWmental health2011-06-23

Djordevic final

32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …

A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…

obstetricsgeneral practicecommunicationsystemclozapine
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

Two suicides occurred at a commercial firing range where individuals gained easy access to firearms. Julia Morris, 23, with documented borderline personality disorder and recent suicide attempt, was discharged from hospi…

psychiatryemergency medicinesystemcommunication
VIChospital2011-06-07

Finding into death of Angelo Lombardo

46y · Male·Coronary artery atherosclerosis

Angelo Lombardo, 45-year-old with schizophrenia, was detained by police under Mental Health Act and brought to ED after acute behavioural disturbance. He received 6mg clonazepam and 20mg olanzapine IM in the ambulance ba…

emergency medicinepsychiatrymedicationsystemclonazepam
VICaged care2011-05-20

Finding into death of Lena Divola

59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…

Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…

general practicepsychiatryproceduralcommunicationwarfarin
VICcommunity2011-05-16

Finding into death of Aaron

14y · Male·injuries sustained in fall from height

Aaron, aged 14, died by suicide from a fall from an 11th-floor balcony. Over 12 years, he had 14 child protection notifications for exposure to domestic violence, neglect, parental substance misuse, poor school attendanc…

paediatricspsychiatrydiagnosticsystem
VIChospital2011-05-04

Finding into death of Ms P

30y · Female·Multi organ failure from hydrochloric acid ingestion

Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 …

psychiatrygeneral practicecommunicationsystemtemazepam
VICaged care2011-04-14

Finding into death of Anderina Laura Sanderson

89y · Female·Ischaemic heart disease in a woman with a history of recent assault

Mrs Anderina Sanderson, 89, died from ischaemic heart disease four days after being assaulted by a male resident with dementia in an aged care facility. The forensic pathologist concluded the assault accelerated her decl…

geriatric medicinepsychiatrysystemcommunicationparacetamol/codeine
SAhospital2011-04-07

Coroner's Finding: WATKINS Maureen

56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis

A 56-year-old woman with bipolar disorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist …

general medicinepsychiatrydiagnosticcommunicationdiazepam
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…

general practicepsychiatrycommunicationdelaytramadol
NThome2011-02-04

Inquest into the death of Emma Jane Claridge

19y · Female·neck compression due to hanging

Emma Jane Claridge, 19, died by hanging at her home on 26 September 2009, nine hours after being granted day leave from the Cowdy Ward psychiatric ward where she was a voluntary patient. She had been admitted following a…

psychiatrycommunicationsystemrisperidone
VIChospital2011

Finding into death of PB

40y · Male·carbon monoxide poisoning

A 40-year-old male sex offender on community-based orders died by carbon monoxide poisoning on 24 August 2009, two days after a serious suicide attempt involving his car. He had been assessed at Frankston Hospital ED on …

emergency medicinepsychiatrydiagnosticcommunication
VIC["community", "home"]["2010-03-03", "2010-02-25"]

Finding into death of Bayden Roy Smith

[47, 77]y · ["male", "female"]·["gunshot injury to head (self-inflicted)", "neck compression"]

Two coronial findings are provided. First, Bayden Roy Smith, 47, died by self-inflicted gunshot wound hours after crisis mental health assessment at Broadmeadows Police Station. The CAT team assessed him as low-risk and …

psychiatryemergency medicinediagnosticcommunication
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide on 2 October 2007 after stepping into the path of a truck. She had …

psychiatrygeneral practicecommunicationsystemstillnox
NSWhome2010-12-13

Coroner's Finding: Paul Justyn Brauer

64y · Male·Large pulmonary embolus (origin undetermined)

Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…

psychiatrygeneral medicinediagnosticmedicationlactulose
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy caused by cardiac …

neurologypsychiatrydiagnosticcommunicationvigabatrin
VICcommunity2010-10-19

Finding into death of Patrick Tolan

55y · Male·Multiple injuries sustained in a fall

Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall from a shopping centre sign. He had jumped from a parapet four years ear…

psychiatryorthopaedic surgerydiagnosticcommunicationmirtazapine
NSWcommunity2010-10-15

Coroner's Finding: Charmaine Margaret Dragun

29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…

Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …

general practicepsychiatrydiagnosticmedicationsertraline
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

Jeremy Barker, a 27-year-old man with bipolar disorder, recent suicide attempts, and explicit stated intention to hang himself, was admitted to Arthur Gorrie Correctional Centre's medical unit for observation as an 'at-r…

psychiatrycorrectional healthcommunicationsystemcarbamazepine
SAcommunity2010-09-27

Coroner's Finding: DALY Michael Barry

53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury

Barry Michael Daly, 53, died from severe burns (75% BSA) and inhalation injury sustained in a deliberately-set house fire on 20 April 2008. He had been detained at Glenside Hospital on 10 April 2008 under the Mental Heal…

psychiatryemergency medicinecommunicationsystem
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