30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds
…c medication with variable compliance. In the weeks before death, he experienced escalating paranoia and delusional ideation, including paranoid beliefs about being persecuted. He presented to hospital on 8 April 2016 wi…
57y · Female·Head injuries resulting in subdural haematoma and global cerebral ischaemic inju…
…later. The coroner identified multiple family violence risk factors in Masatora: mental illness, suicidal ideation, obsessive and jealous behaviour, stalking, and unemployment. Critical clinical lessons include recogniti…
52y · Female·Plastic bag asphyxia and asphyxia in the setting of an irrespirable environment
Diane Bell, a 53-year-old woman with delusional disorder and chronic suicidal ideation, died by argon gas inhalation in June 2017. She had been under ca…
23y · Male·Multiple injuries from being struck by train
…ties included: police (particularly the senior officer) failing to communicate Jalen's expressed suicidal ideation and delusional statements about his partner being murdered to ED staff during bail service; and ED staff …
43y · Male·head, chest and abdominal injuries sustained when intentionally stepping into th…
…Lacroix, a 43-year-old man with a long history of mental health problems, severe depression, and suicidal ideation since 2013, died by suicide on 6 March 2021. On the day of his death, following a police callout for erra…
39y · Male·Injuries sustained in a fall from the Camberwell train station bridge
Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He …
32y · Male·Gunshot wound to the head (Benjamin Green: homicide by William Markee; William M…
…ear, untreated mental health issues characterised by paranoid delusions, obsessive fixation, and suicidal ideation, but never engaged with available mental health services. He had minimal prior psychiatric contact (2008-…
38y · Male·Internal haemorrhage complicating large calibre gunshot wounds to the neck
…ental illness. In the week before his death, he showed increasing evidence of psychotic illness (paranoid ideation, bizarre behavior, delusional statements about being 'possessed by a witch'). During the confrontation, h…
20y · Unknown·Traumatic brain damage complicating gunshot wound to the head
…dual diagnoses; the limitations of 'safety guarantees' in assessing suicide/homicide risk; the danger of delusional jealousy in psychotic illness; and the need for adequate resources to treat established schizophrenia wi…
43y · Male·Gunshot wound to the head
…nd following the killing of his partner Ora Holt. In the months preceding the deaths, Mr Floyd exhibited delusional beliefs that Ms Holt was having affairs, abusing prescription codeine, and reporting him to authorities—…
51y · Male·multiple injuries sustained by a high velocity fall from a height
…erscores risks when people with severe untreated mental illness, experiencing command hallucinations and delusional beliefs, become acutely suicidal and are in remote, high-risk locations beyond easy support networks.
37y · Male·stab wound to the chest penetrating the heart
…and hallucinations instructing self-harm. On 20 April, he presented to emergency department with suicidal ideation and to his psychiatrist with delusional paranoia—neither event prompted reassessment or hospitalization. …
47y · Male·neck compression due to hanging
…homson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (EACIS), atte…
47y · Male·gunshot wound of the head (self-inflicted)
A 47-year-old man with delusional disorder was discharged from mental health detention with a firearm prohibition order. He attended a com…
82y · Male·malignant mesothelioma (palliated)
…temporal dementia but reassessed as likely Alzheimer's disease. During his hospitalization, he developed delusional thoughts, suicidal ideation, and made two suicide attempts. He was placed under successive Inpatient Tre…
23y · Female·multiple blunt force injuries from fall from height
Grace Herington, 23, died from multiple blunt force injuries sustained in a fall from a highway off-ramp during an acute psychotic episode induced by cannabis use. She had attended Royal North Shore Hospital the previous…
33y · Female·Sharp force neck and chest injuries
…assessed at hospital following police welfare responses; he was discharged despite erratic behaviour and delusional ideation, she was assessed and released. Critical deficiencies included police treating family violence …
Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…
…arged on 30 August 2004 against medical advice, declining ECT and antipsychotic medication despite being delusional and at risk. On 19 September she deteriorated acutely with suicidal ideation and was admitted to Princes…
81y · Male·cardiac arrest following neck compression due to hanging
…ally justified; and limited use of interpreters despite language barriers. The patient expressed suicidal ideation multiple times and was found dead from hanging in a recreation room on 18 March 2017. He should have been…
29y · Male·Effects of fire
…en discharged from community mental health services in August 2016 despite chronic suicidal and homicidal ideation, lack of insight into his illness, and refusal to engage with a general practitioner. Key clinical lesson…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.