1,641 results
28y · Male·hanging
A 28-year-old man with treatment-resistant paranoid schizophrenia and substance abuse died by hanging while detained under the Mental Health Act in a closed psychiatric ward. He had chronic auditory hallucinations comman…
12y · Male·Suicide by hanging
A 12-year-old Aboriginal boy living in a remote Queensland community died by suicide by hanging following his placement in alternative care by child protection services. The boy had multiple vulnerabilities including fet…
33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphi…
A 33-year-old man with chronic back pain, depression, morbid obesity and sleep apnoea died in psychiatric custody from respiratory failure due to mixed drug toxicity and probable aspiration. He was heavily medicated with…
24y · Female·Ligature compression injury to the neck (hanging)
Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantle Hospital's Alma Stree…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
51y · Male·neck compression due to hanging
A 51-year-old man on remand in prison died by hanging in his cell. He had a psychiatric history including depression and a family history of suicide, but showed no signs of self-harm risk during nine months of incarcerat…
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…
37y · Female·unlawful killing
Kath Bergamin, a 37-year-old woman, disappeared from her home in Wangaratta, Victoria on 18 August 2002. She had recently left her husband John following years of psychological and physical abuse, obtaining intervention …
gunshot wounds; multiple deaths during police interventions with mentally ill in…
Between October 2003 and February 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the offic…
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …
18y · Male·methadone toxicity
Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …
40y · Male·Haemorrhage from gunshot wound to chest
Lee Andrew Kennedy, a 40-year-old man with a history of mood instability, migraines, and medical treatment through a GP and psychiatrist, died from a gunshot wound to the chest inflicted by Constable Erin Levay during a …
14y · Female·Ligature compression of the neck (suicide)
Gabrielle Mia Tedeschi, a 14-year-old girl with longstanding oppositional and self-harm behaviours and subsequent depression, died by suicide on 14 October 2004 following a ligature compression injury sustained on 11 Oct…
31y · Male·Self-inflicted hanging
Samuel John Mills, a 31-year-old man with chronic schizophrenia, died by suicide in Lotus Glen Correctional Centre's medical ward in 2004. Staff provided adequate supervision on the day of death; Mills denied self-harm i…
50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)
Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…
30y · Male·hanging
Arthur Smith, a 30-year-old man remanded in custody, died by hanging in Yatala Labour Prison on 13 January 2005. He had a complex psychiatric history including borderline personality disorder, chronic depression, polysub…
31y · Male·mixed drug toxicity
Robert Henderson, 31, died from mixed drug toxicity while subject to a community involuntary treatment order for schizophrenia. He was admitted to hospital on 9 July 2005 after his case manager appropriately identified e…
44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…
Peter Gillam, age 44, died from sepsis and pulmonary thromboemboli complicating a ruptured cerebral aneurysm with subarachnoid haemorrhage (SAH). On 16 December 2004, his GP Dr H. referred him urgently for CT head to exc…
24y · Male·diffuse hypoxic ischaemic encephalopathy due to hanging
Colin Craig Sansbury, 24-year-old Aboriginal man, died by hanging while in police custody at Elizabeth Police Station. Critical failures in care included: (1) Inadequate psychiatric assessment at Lyell McEwin Hospital—he…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
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