Coronial

42 results for psychological counselling

NSW2009-12-08

Inquest into the death of rebekah lawrence

34y · Female·Multiple injuries sustained when she stepped off the ledge of a second-floor win…

… established that Rebekah suffered an acute brief reactive psychosis triggered by the course's intense psychological techniques, particularly the 'Inner Child' regression segment, not pre-existing mental illness. The co…

psychiatrysystemcommunication
VIChome2017-02-21

Finding into death of PAR

19y · Male·Plastic bag asphyxia

…ad returned from Thailand in January 2014 reporting excessive groin sweating, which caused significant psychological distress and social withdrawal. In June and July 2014, he was diagnosed with depression and anxiety by…

general practicepsychiatrydesvenlafaxine
VIC2015-09-21

Finding into death of WJ

25y · Male·Pentobarbitone toxicity

…nts had noted concerning signs of depression and isolation in December 2013, with his mother suggesting counselling, but he denied depression and did not persist with psychological support. No suicide note was found, th…

pentobarbitone
VICcommunity2026-02-19

Finding into death of Kathleen Smith

53y · Female·Unascertained (presumed drowned)

…ty about upcoming foot surgery due to severe flatfoot deformity and osteoarthritis. Her GP recommended psychological counselling and prescribed sertraline and diazepam for anxiety management, but Smith declined initial …

general practiceorthopaedic surgerycommunicationdelaysertraline
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

…May 2023 and was initially placed on ARMS (At-Risk Management System) with close monitoring. Following psychological reviews in June, he was removed from ARMS on 8 June 2023 despite his counsellor Rebecca Forster recomm…

psychiatrypsychologysystemcommunicationamitriptyline
WAprison2025-01-03

Inquest into the Death of Christopher John HILLSTEAD

59y · Male·ligature compression of the neck (hanging)

… expectations. After conflict over education, a threatened transfer to the Detention Unit, and a missed counselling appointment, Hillstead barricaded himself in his prison pod and hanged himself. The coroner found that …

psychiatrycorrectional healthcommunicationsystem
VIChome2014-02-12

Finding into death of Sibel Yilmaz

24y · Female·hanging

…itical failure was her family's ignorance of her mental illness; she did not confide in them about her psychological struggles despite their support. Her final counselling session was four days before death. The coroner…

psychologypsychiatrycommunicationsertraline
WAhome2026-01-23

Inquest into the Death of Sean Theo WINMAR (Mr STW)

46y · Male·Complications of ligature compression of the neck (hanging)

…r, and chronic suicidal ideation. The coroner identified critical gaps in care: (1) lack of accessible psychological support—he was referred to a forensic psychology service but remained waitlisted; (2) no structured su…

general practiceaddiction medicinesystemdelaymethamphetamine
VIC2020-10-29

Finding into death of Bo Zhao

31y · Male·Combined Drug Toxicity (amitriptyline and metoclopramide)

…tified depression, anxiety, and despair but he did not engage with recommended psychiatric treatment or counselling. He had cancelled a scheduled psychological consultation on the day of his death. While he presented to…

psychiatrygeneral practicedelayamitriptyline
QLDPodcast2009-10-15

McBride, Edward Alexander

30y · Male·Electrocution from high-voltage electrical current (110,000 V)

…rustration with the medical discharge process; intensive Church of Scientology involvement with unclear counselling outcomes; and intensive contact from Church members on 6-7 February that suggested concerns beyond admi…

VICcommunity2024-09-20

Finding into death of Frank Mellia

39y · Male·Drowning in the setting of a very high blood alcohol level

…as not a confident swimmer and had a history of anxiety, depression, and alcohol misuse. He had ceased psychological treatment due to financial difficulties and did not engage with offered counselling services. The comb…

alcohol
WAhospital2017-07-11

Inquest into the Death of Beasley (also known as Graeme Leslie Syme)

49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …

…d abdominal stab wounds he self-inflicted. Key clinical lessons: his case involved self-harm following psychological crisis after parole cancellation notification. While hospital treatment was appropriate, the coroner f…

emergency medicinetrauma surgerysystemdelaymethamphetamine
WAcommunity2025-09-15

Inquest into the Suspected Death of Nicholas Lutci PAVLIDIS

Male·unascertained

…luding paranoia, anxiety, and isolation; he had ceased taking prescribed medications and withdrawn from counselling. Skeletal remains confirmed as Mr Pavlidis were discovered in October 2024 in Yanchep National Park. Th…

general practicepsychologysystemdelayfluoxetine
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

…ally placed on the Disturbed and Vulnerable list with recommendations for mental health monitoring and psychological follow-up, these recommendations were not implemented. A prior alleged hanging attempt two weeks befor…

psychiatrypsychologydiagnosticcommunication
NSW2022-03-24

Inquest into the death of NG

Male·consistent with the history of hanging

… crisis with low self-harm risk, and maintained monitoring for hypertension. The deceased reported the psychological support unhelpful and did not subsequently disclose worsening mental state to staff. His letters revea…

psychiatrygeneral practice
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

…s not acted upon; clinical assessment notes were fragmented across separated Health Services and Prison Counselling Services; after a suicide attempt on 15 December 2002, he was removed from at-risk monitoring on 3 Janu…

psychiatrycorrectional healthcommunicationsystemantidepressants
WA2019-11-13

Inquest into the Death of Bret Lindsay CAPPER

43y · Male·bronchopneumonia and brain swelling following ligature compression of the neck (…

…spite meeting clear eligibility criteria (chronic suicide risk, difficulty coping with custody). Prison Counselling Service (PCS) resources were critically insufficient (6-7 staff for 955 prisoners), preventing the ongo…

psychiatrypsychologysystemcommunicationheroin
VIC2015-11-30

Finding into death of Yasmina Micheline Acar

2y · Female·acute blood loss as a result of stabbing injuries

…, there is no evidence it would have prevented this tragic filicide. The father had previously attended counselling and family violence programs in 2009 but did not continue engagement with behaviour change intervention…

delaysystemalcohol
VIChome2017-09-21

Finding into death of ALJW

21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia

…d by his 40s," despite clinicians providing reassuring information about good prognosis. He had recent psychological counselling for depression and suicidal ideation after an overdose attempt in early July. His previous…

cardiologypsychologycommunicationsystemheroin
VIC2017-04-20

Finding into death of Helen Julia Mok

49y · Female·Multi-drug toxicity from intentional self-administration of intravenous fentanyl…

…he suicide of a colleague, faced uncertain return-to-work negotiations, and felt stigma around seeking psychological help, the coroner found no clear causal connection between these employment factors and her death. The…

paramedicinepsychiatrysystemfentanyl

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