Coronial

18 results for suicidal ideation (concealed)

SAhome2023-06-30

Coroner's Finding: Doran, Shane Michael

54y · Male·hanging

…lth support, and Mr Doran attended general practitioners who found no evidence of mental health issues or suicidal ideation in August 2020. A psychology appointment was scheduled for 8 September 2020. Mr Doran died befor…

general practicepsychology
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

…rvised by the Alma Street Centre. Key clinical lessons include: (1) the difficulty of detecting concealed suicidal planning in a patient who is intelligent, knowledgeable about mental health systems, and skilled at maski…

psychiatryintensive caresystemdelaypentobarbital
VICcommunity2017-07-10

Finding into death of Khodayar Amini

29y · Male·Effects of fire

…eeting regarding potential visa cancellation following assault charges. Despite communications expressing suicidal intent to support workers and police welfare checks, he was not located or apprehended before his death. …

psychiatryemergency medicinecommunicationsystem
VICmental health2018-03-13

Finding into death of Elizabeth Anne Palmer

39y · Female·Hypovolaemic shock due to incised injury to the wrist

A 39-year-old woman with a history of mental health issues and previous suicide attempts was admitted to a high-dependency psychiatric unit following a suicide attempt involving razor blades and medications. She was plac…

psychiatryemergency medicineproceduralcommunication
TAShome2022-07-21

Coroner's Finding: Moran, Kayla Maree

31y · Female·hanging

… (K10 score of 31 indicating severe mental disorder) yet she was cleared to return to work. She concealed suicidal ideation from family and healthcare providers, who assessed her as having no suicidal thoughts. Referred …

general practicepsychiatrydiagnosticcommunication
VIChome2014-02-12

Finding into death of Sibel Yilmaz

24y · Female·hanging

A 24-year-old woman with longstanding depression, anxiety, and a history of self-harm and suicidal ideation died by hanging following a marital conflict. She had been under care of university counsellors …

psychologypsychiatrycommunicationsertraline
NTmental health2009-04-09

Inquest into the death of Paul Guarini

38y · Male·self-inflicted hanging

…nvoluntary mental health patient. He had presented to hospital multiple times over 4 days with escalating suicidal behaviour, including a dramatic attempted hanging on 10 September while intoxicated (0.18% BAC). On 14 Se…

psychiatryemergency medicinediagnosticsystemparoxetine
VIChome2009-06-02

Finding into death of Mark Andrew Downie

32y · Male·overdose of a combination of chlorpromazine, mirtazapine, and diazepam

…nd recent suicide attempts while imprisoned. Despite hospital staff awareness of his ongoing paranoia and suicidal ideation, he was discharged to his mother's care with verbal advice about medication storage. The decease…

psychiatrysystemdelaychlorpromazine
QLD2018-12-12

Winks, Russell

65y · Male·Gunshot wound to the right upper chest

…, and the importance of rapid assessment of suicide risk with access to means when combined with explicit suicidal intent.

emergency medicinegeneral practiceantidepressant medication
TAShome2025-02-05

Coroner's Finding: de-identified MS

13y · Male·asphyxia as a result of hanging

…6 February 2020. In the weeks before his death, MS engaged in self-harm by cutting his arms and expressed suicidal ideation to close friends through online messaging, but these communications were not disclosed to his pa…

psychologypsychiatrycommunicationsystem
QLD2017-02-10

Sloan, Dane Benjamin

24y · Male·Hypoxic ischaemic encephalopathy due to or as a consequence of being hanged

Dane Benjamin Sloan, a 24-year-old remand prisoner with mental health history including suicidal ideation, hanged himself in the Maximum Security Unit exercise yard at Brisbane Correctional Centre. Alth…

psychiatryemergency medicinesystemdelayamitriptyline
NSW2013-05-16

Inquest into the death of Jason Lee PLUM

37y · Male·Single gunshot wound deliberately self-inflicted while in police custody

…been followed. Key clinical lessons include the importance of recognising mental health comorbidities and suicidal risk in custody settings, and the criticality of thorough risk assessment protocols. Better liaison betwe…

psychiatryemergency medicineproceduralsystem
WAhospital2018-09-10

Inquest into the Death of Theodore Herbert Eric JOHANSEN

50y · Male·Drowning

…year-old man with a history of anxiety and depression, presented to his GP on 28 October 2014 with active suicidal ideation and a detailed plan to drown himself using a block and chain. He was appropriately referred to P…

psychiatryemergency medicinediagnosticcommunicationamitriptyline
TAS2023-06-30

Coroner's Finding: Barron Rickie Underwood

61y · Male·hanging, the result of actions undertaken by the deceased alone, voluntarily and…

…ehavioural changes (mood cycling, paranoia, frustration) in the months before his death, he concealed any suicidal intent from staff and family. Prison health services did not identify him as at-risk. The coroner found t…

psychiatrycorrectional healthsystemantidepressant medication
QLDhospital2007-08-17

Mental Health patient

71y · Male·hypoxic brain injury due to hanging

… His psychiatrist (Dr D.) documented suspicions on 20 July that the patient might be harbouring concealed suicidal thoughts, but this concern was not adequately communicated to nursing staff or family. No formal check of…

psychiatryemergency medicinecommunicationdiagnostictemazepam
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)

…n triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckless driving (190 kph). Dr W. prescribed an antidepressant but made inadequat…

general practiceemergency medicinediagnosticcommunicationcitalopram
QLDmental health2026-01-29

Inquest into the death of Tiesha Marie Derbyshire

18y · Female·Mixed drug toxicity

Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally overdosing on proprano…

psychiatrygeneral practicecommunicationsystempropranolol
TAS2017-06-30

Coroner's Finding: Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford

Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…

…inadequate monitoring during escort. Michael and Mitchell's deaths were not preventable—Michael concealed suicidal intent from all staff, and Mitchell's cardiac event was unexpected in a young healthy-appearing prisoner.…

psychiatrypsychologydiagnosticsystemolanzapine

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