38y · Male·hanging in custody
…custody and died by hanging in a mental health screening unit cell on 3 September 2013. Clinical lessons: suicide risk assessment in custodial settings is inherently difficult and checkbox-based risk tools are poorly de…
14y · Male·hanging
A 14-year-old Aboriginal boy died by suicide by hanging at his school. He had experienced childhood trauma including neglect, domestic violence, and p…
29y · Male·hanging
…Prison on 28 March 2008, 12 days after arrival. His death resulted from systemic failures in psychiatric assessment and care. At Melbourne Assessment Prison, Nurse T D assigned Casey a P3 rating despite six previous suic…
37y · Male·Hanging
…nt life stressors, died by hanging after police attendance at a family violence incident. He had previous suicide attempts (2000, 2009), depression treated with sertraline, and multiple concurrent stressors: marital bre…
86y · Female·Plastic bag asphyxia
… with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, and demonstrated concerning behaviour (suffocating her pet canary, collecting plastic bags). The mental …
39y · Male·Ligature Compression of the Neck (Hanging)
Gerhardus Theron, 39, died by suicide in a remand centre on 25 June 2000 by ligature compression of the neck. He had murdered his wife on 28 Ap…
33y · Female·hanging
A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon monoxide poisoning at…
30y · Female·Hanging
…-old woman with borderline personality disorder, substance abuse history, and exposure to multiple family suicides (father, close friend, partner's mother) presented to Emergency Department after self-harm and suicidal …
85y · Male·Incised wounds to the wrist
…rts. The coroner found care was appropriate given his circumstances. However, the case highlights gaps in suicide risk assessment and mental health support for palliative and aged care patients. Clinical lessons include…
47y · Male·Hanging
…t Townsville Correctional Centre, died by hanging in his cell on 4 July 2019. He had an elevated baseline suicide risk due to a previous 2012 suicide attempt, yet was housed in an old-stock cell with exposed bars above …
34y · Male·Hanging
A 34-year-old man died by suicide by hanging whilst on remand in a correctional facility. He had disclosed his father's suicide 12 years ea…
32y · Male·hanging
A 32-year-old man with bipolar disorder and recent suicide attempt died by hanging in a closed psychiatric ward. He was admitted following overdose and suicidal ide…
53y · Male·Gunshot wound to the head
RC, a 53-year-old man with longstanding depression, died by suicide on 15 April 2014. He was under care of Campbelltown Community Mental Health (CoMHET) when a critical clin…
24y · Male·Hypoxic-ischaemic encephalopathy due to or as a consequence of hanging
… from his biological family, and was involved in complicated personal relationships. Multiple established suicide risk factors were present in his circumstances. The coroner found no direct third-party involvement but n…
54y · Male·carbon monoxide toxicity
A 54-year-old man with a history of depression and previous suicide attempts by carbon monoxide poisoning died from carbon monoxide toxicity following his arrest and questio…
61y · Female·hypoxic brain injury following cardiac arrest due to neck compression due to han…
…in injury following cardiac arrest caused by hanging on a psychiatric ward. She had been admitted after a suicide attempt by overdose and was under a Mental Health Act detention order. Despite appropriate hourly observa…
46y · Male·Neck compression by ligature suspension
Mr Y, a 46-year-old man with a history of alcohol use and family violence perpetration, died by suicide via neck compression by ligature suspension in May 2020. He had expressed suicidal ideation to his wife o…
71y · Male·hypoxic brain injury due to hanging
…a physiotherapy rope that was subsequently used. Key clinical lessons include: the importance of thorough suicide risk assessment with comprehensive documentation; direct communication between psychiatrists and family m…
40y · Male·carbon monoxide poisoning
…r on community-based orders died by carbon monoxide poisoning on 24 August 2009, two days after a serious suicide attempt involving his car. He had been assessed at Frankston Hospital ED on 16 August 2009 following poli…
Female·suicide by firearm
A woman in rural Victoria died by suicide using a firearm. She had presented to her GP with depressive symptoms and was referred to mental health s…
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