Coronial

304 results for chronic suicide risk

VICpsychiatric inpatient unit2020-01-31

Finding into death of Damon Brenden Amiet

25y · Male·Injuries sustained when struck by a train (suicide)

…sonality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serious suicide attempt by hanging. He died the next day after being struck by a train. Critical deficiencies were identi…

psychiatryemergency medicinecommunicationsystemolanzapine
SAhospital2009-08-12

Coroner's Finding: HOPE Maria Kate

55y · Female·hypoxic brain injury complicated by aspiration pneumonia

A 55-year-old woman with chronic schizophrenia died from hypoxic brain injury after suffocating herself with a plastic bin liner while hos…

general practicepsychiatrycommunicationdiagnosticolanzapine
SAcommunity2017-05-29

Coroner's Finding: WESTWOOD John Laurence

63y · Male·neck compression due to hanging

A 63-year-old man with treatment-resistant depression died by hanging. His wife had been maintaining a 'suicide watch' for six weeks prior to his death and telephoned his GP on the morning of his final appointment, ex…

general practicepsychiatrydiagnosticcommunicationmorphine
WAcommunity2011-10-21

Inquest into the Death of Balgo

Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…

This coronial inquiry examined five deaths in Balgo Aboriginal Community over a 24-month period: four suicides by hanging and one death from volatile substance abuse. The suicide rate in Balgo was more than 100 time…

general practicepsychiatrysystemdelaypetrol
VIChome2023-04-13

Finding into death of Martin William Sheahan

57y · Male·Gunshot wounds to the head and abdomen

…cence and permit to acquire, legally purchased a shotgun in Victoria on 17 December 2021 despite planning suicide and harbouring resentment toward Martin over a workplace chainsaw theft incident in 2015. The coroner fou…

general practicepsychiatrycommunicationsystemmirtazapine
NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

…a and suicidal ideation four months later. He was readmitted to hospital as a voluntary patient with high suicide risk and permitted family leave. The coroner found no error in the clinical decision to cease medication,…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

…2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days earlier following workplace stress, shoulder injury, loss of driver…

psychiatryemergency medicinediagnosticcommunicationcitalopram
TAShospital2017-08-22

Coroner's Finding: AH - de-identified

37y · Female·asphyxia due to hanging

A 37-year-old woman with major depression and Crohn's disease was admitted to hospital following a suicide attempt. She was discharged after less than two days following clinical improvement, against her husband'…

psychiatryemergency medicinediagnosticcommunicationescitalopram
TAShome2022-08-18

Coroner's Finding: Daw Rodney Keith

63y · Male·acute blood loss due to self-inflicted sharp force incisional wounds of the thro…

A 63-year-old man with multiple chronic conditions including psoriatic arthritis, depression, prostate cancer, and recent dental issues died by s…

psychiatryemergency medicinecodeine
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

… a 51-year-old man with acquired brain injury from a 2003 motorcycle accident, depression, and history of suicide attempts. Critical information about his mental health and vulnerability was not communicated between the…

psychiatryforensic medicinecommunicationsystemoxycodone
VIChome2026-03-19

Finding into death of Aisha Natasha Khan

44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…

…al polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prior suicide attempts. On 12 September 2023, she called ACIS (Acute Crisis Intervention Te…

psychiatryemergency medicinesystemdelaytapentadol
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

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

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell…

psychiatrypsychologysystemcommunicationamitriptyline
VIChome2015-07-15

Finding into death of Margaret Helen McCall

60y · Female·hanging

Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ke…

pain medicinepsychiatrycommunicationsystemketamine
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 be…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
TAShome2023-05-10

Coroner's Finding: PQ de-identified

51y · Male·self-inflicted chest injuries due to gunshot wound to chest

…medical information from his GP, his depression and alcohol abuse would have been revealed, enabling proper risk assessment. The clinical lesson emphasises the importance of: documenting reasons for ceasing psychiatric m…

general practicepsychiatrycommunicationsystemdesvenlafaxine
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

29y · Male·ligature compression of the neck (hanging)

Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures i…

correctional healthpsychiatrysystemcommunication
NSWmental health2024-08-30

Inquest into the death of Corey SELBY

48y · Male·Gunshot wound to the chest during a police operation

…ng depression, alcohol use disorder (consuming approximately a carton of beer daily by January 2023), and chronic back pain. After presenting to Tenterfield Hospital on 31 October 2022 threatening harm to himself and fa…

psychiatrygeneral practicesystemduloxetine
QLD2013-04-18

McCarty, Lawrence

45y · Male·exsanguination due to incised wound to neck

Lawrence McCarty, a 45-year-old man in custody on remand, died by suicide in prison on 30 April 2011 by slashing his neck with a dismantled razor blade. Clinical lessons include: …

general practicepsychiatrydiagnosticcommunicationsertraline
VICcommunity2010-06-11

Finding into death of Kelvin Lea Swab

34y · Male·Hanging

Mr Kelvin Swab, a 34-year-old with chronic mental illness including borderline personality disorder and longstanding suicidal ideation, died by hang…

psychiatrycommunicationdiazepam
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

…with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, sertraline, gabapen…

psychiatrygeneral practicecommunicationsystemtapentadol
19101116

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.