Coronial

654 results for mental health issues

VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

…ce Intervention Order and police involvement on multiple occasions. While medical services from his GP and mental health providers were reasonable, systemic issues emerged: Victoria Police's L17 risk assessment form was …

psychiatrygeneral practicecommunicationsystemvenlafaxine
TAShome2019-11-15

Coroner's Finding: Mason, Alison Henderson

66y · Male·Unknown - death presumed to have occurred but cause undetermined

…isappearance and presumed death of Alison Henderson Mason, an 66-year-old man with cardiac, cognitive, and mental health issues who disappeared from his home in Devonport, Tasmania on 8 October 1968. He left his home at …

NSWhome2015-10-23

Inquest into the death of Mary-Anne TURNER

58y · Female·Unknown - cause and manner of death remain undetermined

…th. Post-mortem toxicology detected amitriptyline, nortriptyline, and methadone. Mary-Anne had significant health comorbidities (Hepatitis C, emphysema, severe prescription drug addiction), mental health issues including…

pathologytoxicologymethadone
VIChospital2016-02-15

Finding into death of Mairi Elizabeth Noble

57y · Female·Injuries sustained when struck by a train

…erly documented or executed. Critical systemic failures included: communication gaps between ED and ECATT (mental health crisis team), incomplete handover of care plans, inaccessible medical records, and unclear document…

emergency medicinepsychiatrycommunicationsystemmirtazapine
ACThospital2022-06-30

Inquest into death of DEAN CHRISTOPHER BRICE (No. 2)

25y · Male·Cardiorespiratory arrest due to aspiration pneumonia and hypoxic-ischaemic encep…

…c-ischaemic encephalopathy. He was subject to a Psychiatric Treatment Order at death. The coroner found no issues with the quality of care, treatment or supervision provided by ACT Mental Health services in the community…

psychiatryemergency medicinemethamphetamine
TAScommunity2019-06-18

Coroner's Finding: DI

30y · Male·Head injuries sustained from intentional motor vehicle collision with oncoming t…

A 30-year-old man with untreated long-standing mental health difficulties died by intentionally driving his vehicle into an oncoming truck on 5 September 2017. …

psychiatryemergency medicinealcohol
WAmental health- 11 April 2014

Inquest into the Death of Luke Isaac FORKIN

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

Luke Isaac Forkin, a 28-year-old man with a long history of substance abuse and mental health issues, died by suicide while absent without leave from Graylands Hospital. He had been admitted in…

psychiatrysystemdelayamphetamine
WA2019-05-09

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

36y · Male·Ligature compression of the neck (suicide by hanging)

… exhibited frustration by head-banging when told he must remain in custody. Critical information about his mental state, medication non-compliance, and self-harming behaviour was inadequately communicated between SERCO (…

psychiatryforensic medicinecommunicationsystemmethamphetamine
NSWmental health2025-08-13

Inquest into the death of Allyson Bailey

42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…

…olar damage complicated by mixed drug toxicity (baclofen and pregabalin toxicity) whilst in seclusion in a mental health unit. Critical clinical failures included: inappropriate transfer from ICU to a mental health ward …

emergency medicineintensive carediagnosticcommunicationbaclofen
VICcommunity2017-07-10

Finding into death of Khodayar Amini

29y · Male·Effects of fire

…and after deliberately pouring petrol over himself and igniting it. He had been diagnosed with significant mental health issues during immigration detention and was distressed about an upcoming Department of Immigration …

psychiatryemergency medicinecommunicationsystem
TASmental health2021-05-21

Coroner's Finding: Hanson, Sungwaan

64y · Female·stage IVB metastatic adenocarcinoma of the rectum

… metastatic adenocarcinoma of the rectum at the Roy Fagan Centre on 27 May 2020. She had been subject to a Mental Health Act treatment order at the time of her death. A rectal mass was identified on examination in Novemb…

psychiatrygeneral medicine
NSWhome2016-07-05

Inquest into the death of Jason BRITTEN

30y · Male·Cause of death remains uncertain; likely drug-related but not established

Jason Britten, a 30-year-old man with a long history of heroin use and mental health issues including previous suicide attempts, was found dead at his home in February 2015 after appro…

psychiatryaddiction medicinedelayheroin
NSW2025-01-16

Inquest into the death of Tammy Michelle Shipley

47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffecti…

…022 for minor shoplifting offences. Critical failures included: NSW Police failed to record her documented mental health history in custody records despite having multiple recent interactions with her showing mental illn…

psychiatryemergency medicinediagnosticcommunicationbuprenorphine
TAShome2020-07-16

Coroner's Finding: Alsop, Olaf Paul

54y · Male·asphyxia due to hanging

A 54-year-old man with long-standing mental health issues, substance use disorder, and terminal lung cancer died by hanging. He had a history of suici…

general practicepalliative carecodeine
VICcommunity2021-05-07

Finding into death of Michael Gerald Anthony

26y · Male·Hypoxic ischaemic encephalopathy in the context of neck compression

A 26-year-old man with longstanding mental health issues and substance use died from hypoxic ischaemic encephalopathy caused by neck compression duri…

forensic medicineintensive carealcohol
VIChospital2013-12-19

Williamernestjolly 486312pdf

66y · Male·End stage chronic obstructive pulmonary disease

…lation would be futile given his end-stage lung disease. The coroner found the custodial management of his mental and physical health issues appropriate, noting mental health issues did not contribute to death. Cause: na…

respiratory medicinepsychiatry
VIChospital2014-02-10

Finding into death of Glenn Stewart Hayes

36y · Male·Hypoxic/ischaemic encephalopathy and hanging

…career. In the preceding days, he displayed severe mood swings, aggressive behaviour, and anger management issues related to amphetamine and cannabis use. He explicitly stated suicidal intent to multiple contacts. Clinic…

intensive careemergency medicinediagnosticsystemmethamphetamine
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
SAhospital2020-11-02

Coroner's Finding: BROWN Graham Douglas

79y · Male·combined cardiac, respiratory and renal failure as terminal events on a backgrou…

…ed at Noarlunga Hospital from combined cardiac, respiratory and renal failure. He was subject to a Level 2 Mental Health Act Inpatient Treatment Order at the time of death, making this a mandatory inquest. The coroner fo…

psychiatryemergency medicinemorphine
WAcommunity2020-03-04

Inquest into the Suspected Death of Gordon COLLEY

38y · Male·Hallucination, dehydration and exposure, exacerbated by untreated mental illness…

…isappeared on 7 December 1997 from Mundiwindi Station near Newman, Western Australia. He was known to have mental health issues requiring anti-psychotic medication (Haloperidol) and held strong cultural beliefs. He belie…

psychiatrygeneral practicehaloperidol
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