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SA2004-08-06

Coroner's Finding: FREDERICKS Jeffrey Ronald

41y · Male·haemorrhage due to incised wounds to left and right cubital fossae

Jeffrey Ronald Fredericks, aged 41, died in Adelaide Remand Centre custody from haemorrhage due to self-inflicted incised wounds to both cubital fossae. Critical clinical lessons: screening tools identified significant s…

general practiceemergency medicinediagnosticcommunicationdosulepin
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine
WAhome2004-06-04

Inquest into the Death of Paul John Long

37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion

Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …

psychiatrygeneral practicecommunicationsystemquetiapine
SAmental health2004-04-20

Coroner's Finding: TAYLOR Michael Jason

27y · Male·Not determined; olanzapine toxicity suspected but regarded by expert evidence as…

Michael Jason Taylor, aged 27, died on 26 February 2000 while detained at Glenside Hospital under the Mental Health Act 1993. He was a patient with chronic schizophrenia, borderline intelligence, and a history of drug-se…

psychiatrytoxicologysystemcommunicationolanzapine
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

Natasha Quartermaine, a 25-year-old female prisoner at Bandyup Women's Prison in Western Australia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, person…

psychiatrygeneral practicecommunicationsystemzuclopenthixol
SA2004-02-13

Coroner's Finding: DEWSON Brian Keith

33y · Male·hanging

Brian Dewson, a 33-year-old man with a 12-year history of drug and alcohol abuse, multiple psychiatric assessments (antisocial personality disorder, depression), and prior suicide risk designations died by hanging in Por…

psychiatrycorrectional healthsystemcitalopram
WA2004-02-10

Inquest into the Death of Dylan Robert Green

26y · Male·Ligature Compression of the Neck (Hanging)

Dylan Robert Green, a 26-year-old remand prisoner at Hakea Prison, died by hanging on 11 July 2002. He had a history of serious mental illness, including psychotic episodes with delusional beliefs, and a previous suicide…

psychiatrycorrectional healthsystemcommunicationolanzapine
SAhome2004-01-29

Coroner's Finding: ARANY Eva and Jeno

Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…

An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…

psychiatrygeriatric medicinecommunicationsystemparoxetine
NThospital2004-01-21

Inquest into the death of Rita Anderson

43y · Female·unknown

Rita Anderson, a 43-year-old Aboriginal woman with chronic alcohol-related organic brain damage, was admitted to Royal Darwin Hospital in March 2002 for stabilization and placement planning. Unable to safely live indepen…

psychiatrygeneral medicinesystemcommunicationdroperidol
NTmental health2003-12-19

Inquest into the death of Sarah Higgins

19y · Female·hypoxic encephalopathy as a result of attempted hanging

A 19-year-old woman with psychosis and depression died from hypoxic encephalopathy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk…

psychiatrygeneral practicesystemcommunicationhaloperidol
NThome2003-12-19

Inquest into the death of Sunjay Chandra

25y · Male·hanging (self-inflicted)

A 25-year-old man with schizophrenia died by suicide while on a Community Management Order following discharge from psychiatric hospital. He had been effectively stabilized on clozapine for years, but in late 2001 reques…

psychiatrypsychologycommunicationsystemclozapine
SA2003-12-18

Coroner's Finding: LINDSAY Margaret

38y · Female·neck compression due to hanging

Margaret Lindsay, 38, died by hanging in Adelaide Women's Prison on 23 May 2001 whilst remanded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite…

psychiatrycorrectional healthcommunicationsystemdiazepam
SAcommunity2003-10-29

Coroner's Finding: NICHOLLS Geoffrey Douglas

41y · Male·Shotgun wound to the left side of the chest with laceration of the heart and hae…

Geoffrey Douglas Nicholls, aged 41, was shot by police during an armed incident at Oodnadatta, South Australia. He had a history of mental illness including depression with suicidal ideation, Bartter's syndrome (causing …

emergency medicinepsychiatrysystemdelay
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
WA2003-04-29

Inquest into the Death of Mark Anselo Ugle

36y · Male·Acute on Chronic Myocardial Infarction

Mark Anselo Ugle, a 36-year-old Aboriginal man with a significant history of cardiac problems, seizures, and non-compliance with medication, died in East Perth Lockup on 9 December 2000 from acute on chronic myocardial i…

cardiologyemergency medicinecommunicationsystemmethamphetamine
SAhome2003-04-11

Coroner's Finding: YIALAS Dimitrios

23y · Male·neck compression due to hanging

A 23-year-old male with drug-induced psychosis died by hanging. He had a long history of substance abuse and behavioural problems, with multiple presentations to hospital and mental health services. In March 2001, he was…

psychiatrygeneral practicecommunicationsystemamitriptyline
SA2003-03-20

Coroner's Finding: VARCOE Alexander Wayne Keith

24y · Male·hanging

Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…

psychiatrygeneral practicesystemcommunication
WA2003-03-07

Inquest into the Death of slater

28y · Male·Ligature compression of the neck (hanging)

Evan Charles Slater, 28, died by ligature compression of the neck (hanging) in Cell D7, Unit 10 of Hakea Prison on 12 March 2001. He was on remand facing assault and restraining order breach charges stemming from domesti…

psychiatrycorrectional healthcommunicationsystemanti-depressant medication
SA2003-01-17

Coroner's Finding: ALLEN Craig Mark

29y · Male·Hanging

Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…

correctional healthpsychiatrycommunicationsystemfluoxetine
SAmental health2003-01-10

Coroner's Finding: MYNHART Johann George

77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)

A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …

psychiatryemergency medicinecommunicationdelay
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