Coronial

308 results for family crisis

WAcommunity2019-07-17

Inquest into the Death of Mark Quenton FLEURY

38y · Male·ligature compression of the neck (hanging)

…anoia following a medication change from risperidone depot to aripiprazole (Abilify) in December 2015. His family repeatedly expressed concerns about his deteriorating mental state and suicide risk. However, clinicians a…

psychiatryemergency medicinecommunicationsystemrisperidone
VICcommunity2023-10-26

Finding into death of KDR

51y · Male·Neck compression from hanging

… and provided reasonable care. However, the coroner noted systemic limitations in Victoria's mental health crisis response services, referencing the Royal Commission into Victoria's Mental Health Care System's recommenda…

psychiatryemergency medicinemidazolam
TAScommunity2015-07-29

Coroner's Finding: Rivelli, Andrea

27y · Male·Self-inflicted wounds

…ent meditation retreat. The coroner observed that at this critical time, Mr Rivelli lacked access to close family or community support systems that might have enabled timely intervention. No recommendations were made, bu…

VIChospital2024-10-14

Finding into death of Bekkie-Rae Curren

28y · Female·Blunt head injury

…injury sustained in an assault by her domestic partner on 26-27 November 2019. She had disclosed extensive family violence to support services, including strangulation, physical assault, sexual coercion, and monitoring. …

VIChome2012-10-09

Finding into death of Sue Hui Wang

15y · Female·compression of the neck

…y her mother, Li Zhen Gao, who died by suicide in the garage. Sue's death occurred in the context of acute family stress following her parents' separation on 22 July 2010. Sue showed emotional distress in the preceding w…

general practiceforensic medicinecommunicationdelay
TAScommunity2018-03-19

Coroner's Finding: Hamlyn, Michael William

Male·hanging

…in bushland in July 2016, discovered three months later in October 2016. He had a history of mental health crisis at age 17 following a police interaction, including a Panadol overdose and psychiatric treatment, but ther…

psychiatryemergency medicinesystem
QLDhome2016-08-26

Winbank, Leslie Geoffrey

53y · Male·Self-inflicted gunshot wound to the head

… and prostate cancer, died from a self-inflicted gunshot wound during a police siege at his home. He had a family relationship breakdown and was on pain relief medication including oxycodone. Early on 30 November 2014, h…

psychiatrypain medicineoxycodone
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

…f Headspace counselling. Clinicians did not utilise adequate senior psychiatric review of an adolescent in crisis. The coroner noted that terminating the established therapeutic relationship with Dr O. may have removed a…

psychiatrygeneral practicediagnosticcommunicationtemazepam
TAShome2022-06-15

Coroner's Finding: Duggan, Philip Craig

52y · Male·self-inflicted gunshot wound to the head (contact range gunshot wound to the mou…

…ted gunshot wound at his home while police officers were present attempting to apprehend him for a serious family violence incident. Earlier that evening, the man poured petrol over his partner and himself, threatening t…

NSW2018-06-22

Inquest into the death of KS

24y · Male·gunshot wound to the head

… a siege using containment and negotiation strategies. Despite concerted efforts by police negotiators and family support, the deceased self-inflicted a fatal gunshot wound on 18 March 2016. The inquest examined negotiat…

psychiatrycommunicationsystem
VIChome2025-11-04

Finding into death of Kon Maximos

62y · Male·Shotgun injury to the head

…62, died from a self-inflicted shotgun wound to the head on 15 October 2023. He was in acute interpersonal crisis following marital separation, family estrangement over infidelity, and police intervention for family viol…

psychiatrypsychologydiagnosticcommunicationmirtazapine
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"]

…onial 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 dischar…

psychiatryemergency medicinediagnosticcommunication
VICcommunity2022-07-13

Finding into death of Dane Warren Simpson

52y · Male·Hanging

…act with mental health services including a psychiatrist, psychologist specialising in OCD, and a hospital crisis triage service. While he denied suicidal ideation on formal assessment in May 2019, he expressed increasin…

general practicepsychiatrycommunicationfluoxetine
TAScommunity2021-10-15

Coroner's Finding: Lacroix, Adrian

43y · Male·head, chest and abdominal injuries sustained when intentionally stepping into th…

…th no other person able to have prevented it. The case highlights the severe risk when acute mental health crisis, alcohol intoxication, and established suicidal intent converge.

psychiatryemergency medicinealcohol
VICcommunity2012-12-10

Finding into death of Benjamin Jason Pappas

28y · Male·consistent with drowning

…March, Ben presented to Alfred Hospital ED expressing suicidal thoughts but was discharged with outpatient crisis follow-up. On 4 March, after learning of Lynette's death and being visited by the Crisis Assessment Team, …

general practicepsychiatrysystemcommunicationheroin
VIChome2023-10-10

Finding into death of Abdurrahman Coskun

53y · Male·Neck compression in the circumstances of hanging

…old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed to respond…

psychiatrygeneral practicecommunicationsystemmirtazapine
VICcommunity2012-03-23

Finding into death of Simon Rhys MacQueen

34y · Male·head and neck trauma (train impact)

…was made to coordinate care between mental health services and his GP despite co-shared management, and no crisis/emergency plan was developed at his first outpatient appointment on 28 November 2008. The coroner found th…

psychiatrygeneral practicecommunicationsystemrisperidone
WAcommunity2025-08-11

Inquest into the Suspected Death of Simon Brian HARRINGTON

34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…

…triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle advocated for improved family involvement in his mental health care at the Alma Street Centre, expressing concerns about medication side…

psychiatryemergency medicinecommunicationquetiapine
VIChome2022

Finding into death of TCW

43y · Female·Neck compression

… care but did not fully appreciate the extent of OMP's violence toward TCW at home. Critically, adolescent family violence was not identified or assessed. TCW reached breaking point after OMP stole a car and was arrested…

psychiatrypsychologysystemdelayfluoxetine
VICcommunity2013-12-19

Finding into death of David Yannick Hollingsworth

29y · Male·Gunshot injury to the head

…r-old man with depression, died from a self-inflicted gunshot wound. He had expressed suicidal ideation to family members on 8 December 2012, contacted crisis services, and was observed acting strangely near Parliament H…

psychiatrygeneral practicecommunicationsystemmirtazapine
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