Coronial

308 results for family crisis

NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

…8) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered with antidepressants and lithium, but his firearms licence wa…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
VIChome2011-11-02

Finding into death of James Thomas Smith

45y · Male·single penetrating stab wound to the chest

… during an altercation with his partner Jacqui Holmes in January 2008. The incident occurred weeks after a family violence intervention order was made following his assault on Jacqui in November 2007. Critical system fai…

emergency medicineforensic medicinecommunicationsystem
NSWcommunity2016-07-15

Inquest into the deaths of Susana Castillo, Liam Milne and Darren Milne

Unknown·Multiple injuries (road crash)

Three family members died on 1 February 2015 when a car was deliberately driven into a tree: Darren Milne (42), his wif…

psychiatrygeneral practicesystem
VIChome2015-05-08

Finding into death of Divesh Sharma

5y · Male·unascertained

…airment and mood changes following a motor vehicle collision in December 2011, appears to have exposed the family to chloroform before suffocating them, then died by suicide. The family had unrecognised history of contro…

rehabilitation medicineneurologycommunicationsystemchloroform
SAmental health2011-08-26

Coroner's Finding: XU Yan Yi

50y · Female·compression of the neck consistent with hanging

…December that contradicted concurrent high-risk assessments; failure to obtain collateral information from family despite repeated recommendations; inappropriate risk categorization at admission; and insufficient observa…

psychiatrygeneral practicediagnosticcommunicationsertraline
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

… Recommendations for improvement included direct engagement with consumers aged 16+, refresher training on crisis assessment in neurodivergent populations, and environmental ED modifications for those with sensory sensit…

psychiatryemergency medicinecommunicationsystemcannabis
NSWcommunity2026-01-20

Inquest into the disappearance and suspected death of AL

35y · Male·The available evidence does not allow for any finding to be made as to the cause…

…ng home, and was last seen walking toward the Macquarie Lighthouse cliff line. Multiple notes addressed to family and employers indicated premeditated suicide. Despite extensive police investigation and searches, his bod…

psychiatrypsychology
NSWcommunity2019-03-26

Inquest into the death of Eeva DORENDAHL and Greg HUTCHINGS

35y · Male·The medical cause of death is unknown

…rgs throughout 2013. His mental health deteriorated significantly from September 2013, particularly due to family law custody disputes over his 4.5-year-old daughter Eeva. He discontinued contact with healthcare provider…

general practicepsychologydiazepam
VIChome2015-11-27

Finding into death of Sherry Ann Robinson

38y · Female·multiple stab injuries to the chest and abdomen

…apprehended by police under mental health legislation following a volatile episode triggered by an adverse family court decision. During his brief hospital assessment, he expressed a desire to harm his ex-partner with a …

psychiatryemergency medicinecommunicationsystemquetiapine
VIC2016-04-04

Finding into death of Werner Viertmann

83y · Male·Multiple injuries sustained in collision with train (pedestrian)

…ical lessons involve capacity assessment, safer aged care discharge policies, and system-level failures in crisis communication.

geriatric medicinepsychiatrycommunicationsystem
WAhome2024-09-11

Inquest into the Death of Stephen Kenneth SHERWOOD

31y · Male·ligature compression of the neck (hanging)

…il 2022, both resulting in police welfare checks. On 12 April 2022, two probationary constables attended a family violence complaint and served a Police Order. Although Stephen's sister and partner disclosed suicidal con…

psychiatryemergency medicinecommunicationmethamphetamine
WA2021-11-03

Inquest into the Suspected Death of Peter JOHNSON

71y · Male·undetermined - likely injuries sustained from fall at The Gap, but cannot exclud…

…r, disappeared on 17 October 2019 from The Gap in Torndirrup National Park, Albany. He had previously told family and friends he would end his life rather than undergo chemotherapy or palliative care if his cancer progre…

oncologygeneral practicecommunication
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

…is presentation, the care fell short of best practice by: failing to obtain corroborative information from family despite guidelines requiring this; not reconciling discrepancies between dispatch notes and Jet's account;…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
VIChome2012-02-14

Finding into death of Leigh Glenn Travaglia

30y · Male·Carbon monoxide poisoning

…htened awareness of caregiver wellbeing, provide mental health support proactively, and recognise signs of crisis in parents of dependent children with complex needs.

benzodiazepines
VIChospital2021-02-26

Finding into death of MrJ

22y · Male·Drowning

…atient is coherent, provide sufficient security resources in ED, and avoid delayed assessments waiting for family presence when safety risks are present.

emergency medicinepsychiatrysystemdelayMDMA
WAhome2016-07-21

Inquest into the Deaths of Jessica Rose CUZENS and Jane Lesley Margaret CUZENS and Heather GLENDINNING

46y · Female·Ms Glendinning: multiple sharp force injuries (suicide); Jane Lesley Margaret Cu…

…nning, severely mentally ill with chronic paranoid delusions exacerbated by cannabis abuse and stress from family court proceedings, killed her daughters Jane and Jessica on 5 December 2011, then took her own life. While…

psychiatrygeneral practicecommunicationsystemcannabis
VIChospital2023-08-11

Finding into death of Mr H

58y · Male·aspiration pneumonia complicating sigmoid volvulus, in a man with multiple scler…

Mr H, a 58-year-old man with end-stage multiple sclerosis and recurrent sigmoid volvulus, presented to Box Hill Hospital on 25 January 2023 with abdominal pain and distension. He underwent rectal tube insertion via sigmo…

surgeryemergency medicinemorphine
VIChome2026-04-14

Finding into death of Justin James Filardo

45y · Male·Gunshot wounds to the head and left shoulder

…nt, recognising early relapse signs (behaviour change, sleep/hygiene disruption), and the critical role of family communication in mental health crises. Earlier intervention when medication non-compliance was detected mi…

psychiatrygeneral practicesystemdelayclozapine
TAS2025-07-04

Coroner's Finding: de-identified CF

24y · Male·blunt trauma and drowning due to intentional jumping from Tasman Bridge

…ance; inadequate follow-up after psychiatric discharge (single GP visit); no documented safety planning or crisis contact details; international students may have unique stressors and isolation; close liaison with workpl…

psychiatryemergency medicinedelaycommunicationolanzapine
NSW2019-04-03

Inquest into the disappearance and suspected death of Luxing Li

28y · Male·unknown

This inquest concerned a 28-year-old man who disappeared on 18 October 2017 from the Skillion, a coastal cliff location known as a suicide site near Terrigal, NSW. The coroner found he died on or soon after that date in …

19101116

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