Coronial

23 results for maternal mental health disorder

VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

JH, a 15-year-old with Autism Spectrum Disorder and Major Depressive Disorder, died by electrocution at home on 16 September 2019. He had been experienci…

psychiatrypaediatricssystemcommunicationfluoxetine
VICcommunity2019-10-30

Finding into death of Sanaya Sahib

1y · Female·Suffocation

… and stress. Clinical lessons include the missed opportunity for repeat postnatal depression screening by maternal and child health nurses following Ms Nikat's changed circumstances in March 2016. Although Ms Nikat had a…

obstetricspsychiatrysystemdelaymethamphetamine
NSWhome2025-05-30

Inquest into the Death of K.P.

3y · Male·unascertained

KP was a 3-month-old with intrauterine growth restriction born to a mother with documented mental health issues and cannabis use. Despite referral to SAFE START and child protection involvement, care coor…

paediatricspsychiatrysystemcommunicationcannabis
VIChome2025-08-20

Finding into death of GFD

2y · Male·Complications of malnutrition

…alnutrition had developed over weeks to months. The child's mother, TFC, who had an acquired brain injury, mental health conditions (borderline personality disorder, PTSD, depression), and history of family violence, was…

paediatricsforensic medicinesystemcommunication
WAcommunity

Inquest into the Death of Paul DICKSON

34y · Male·multiple injuries

… His mother had died in mid-2013, a significant psychosocial stressor. Community follow-up by Osborne Park Mental Health Clinic on 6 November 2013 noted low-risk presentation consistent with baseline, though the patient …

psychiatryemergency medicineolanzapine
QLDhome2021-02-17

B, an eleven week old infant - Non-inquest findings

0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying

…ld protection assessment addressing totality of risks; collaborative practice between child protection and health services; and counselling families on safe sleep practices. The case highlights failures to sufficiently w…

paediatricspathologysystemcommunicationcannabis
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been dia…

psychiatrygeneral practicecommunicationsystemolanzapine
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …

paediatricspsychiatrysystemdelay
QLDhospital2011-06-24

(C) a 15 month old child

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

…pervision failures by parents; (2) failure of government agencies (NSW and Queensland child protection and mental health services) to share critical child protection history due to witness protection program complication…

paediatricsplastic and reconstructive surgerycommunicationsystemrisperidone
NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

…: the child protection service had closed the case file prematurely in February 2015 despite known severe maternal mental illness and prior child removal; the community mental health team discharged the mother on 9 Septe…

general practicepsychiatrycommunicationsystemtriflouperazine
SAhome2000-03-08

Coroner's Finding: KAPTSIS Michael Vasilious

3y · Male·smothering

A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psychiatric care was inadequa…

psychiatryemergency medicinelithium carbonate
VIC2016-08-22

Finding into death of Helen

68y · Female·Multiple injuries sustained in a fall

68-year-old woman with bipolar affective disorder and history of suicide attempts died by jumping from a car park rooftop on 14 April 2015. She had been di…

psychiatryemergency medicinesystemmirtazapine
QLDcommunity2016-05-03

Foster, Troy Martin

32y · Male·gunshot wounds to the trunk

…bstance abuse and violence, died following a police shooting. On 24 November 2014, he was detained under a Mental Health Act Emergency Examination Order after telling police he intended to kill himself. At Gold Coast Uni…

psychiatryemergency medicinecommunicationsystemalcohol
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

…evere psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 15mg prescribed by a psychiatrist, but had a pattern of medication no…

psychiatrygeneral practicecommunicationsystemolanzapine
TAShome2025-06-24

Coroner's Finding: Infant W and Infant P

Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…

…ch case), inadequate risk assessment despite identified high-risk factors (family violence, substance use, mental health issues, parental inability to care for other children), failure to provide safe sleeping education …

paediatricspsychiatrydiagnosticcommunicationmethadone
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to polic…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
NThome2026-06-19

Inquest into the death of RL

17y · Male·Suicide by self-inflicted hanging

RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health

psychiatrypsychologycommunicationdiagnostic
NSWcommunity2022-07-15

Inquest into the death of C S

5y · Male·Presumed drowning

…9 months, died by presumed drowning on 2 March 2017 in the Murray River, Moama NSW. His mother LS, who was mentally unwell and using ice, forcibly held him underwater. Multiple agencies—FACS, NSW and Victoria Police, men…

paediatricspsychiatrydiagnosticsystemmethamphetamine
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

…ality on 18 June, attended police station in crisis on 21 June, and was admitted on 21 June via Section 10 Mental Health Act order. Despite expressing repeated suicidal ideation and threats during admission, she was asse…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhome2016-07-21

Inquest into the Deaths of Heather GLENDINNING and Jessica Rose CUZENS and Jane Lesley margaret CUZENS

46y · Female·Ms Glendinning: multiple sharp force injuries (suicide); Jane Cuzens: multiple i…

…hters and then herself. Ms Glendinning had a longstanding history of paranoid delusions, cannabis use, and mental health difficulties dating back to 2000. Over the decade preceding her death, multiple agencies—mental hea…

psychiatrypsychologycommunicationsystemcannabis

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