Coronial

346 results for mental health distress

SAmental health2008-10-16

Coroner's Finding: SWEETLAND Charles James

28y · Male·hanging

…th treatment-resistant paranoid schizophrenia and substance abuse died by hanging while detained under the Mental Health Act in a closed psychiatric ward. He had chronic auditory hallucinations commanding self-harm and h…

psychiatrysystemproceduralsodium valproate
VICcommunity2021-03-03

Finding into death of Michael Brian Sanders

57y · Male·Unascertained causes; presumed suicide by jumping from cliffs

…e sale, and workplace management pressures with a performance meeting scheduled. His GP confirmed no prior mental health consultations. The coroner did not identify clinical factors but rather attributed the death to cum…

QLDhospital2011-09-20

Long, Kerry-Ann

42y · Female·Subarachnoid haemorrhage as a consequence of rupture of saccular aneurysm of the…

…taff, followed by paramedic transport and ICU management. An independent medical review confirmed adequate health assessment on reception to custody, appropriate medication provision, and timely emergency response. Death…

emergency medicineneurosurgerymethadone
VICcommunity2020-11-06

Finding into death of Jessica Morgana Wilby

45y · Female·Compression of the neck in circumstances of hanging

…rming three roles simultaneously in an organisationally toxic workplace. Within weeks she became severely distressed with major depressive disorder and insomnia. Despite clear evidence of acute distress on 15 March 2018 …

psychiatrypsychologysystemcommunicationantidepressants
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

…0-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by financial sca…

psychiatrygeriatric medicinesystemolanzapine
SA2019-05-23

Coroner's Finding: HARRIS Philip Michael

30y · Male·exsanguination due to division of left brachial artery

…ery. He had a longstanding history of self-harm behaviour, borderline antisocial personality disorder, and mental health presentations. Despite being identified as high-risk on admission and placed under intensive observ…

psychiatryemergency medicinecarbamazepine
VIChome2023-10-02

Finding into death of Student FSB

35y · Male·Multiple injuries sustained in a fall from a height

…tained prescriptions for sertraline and aripiprazole before moving to Australia. Critically, no Australian health services were aware of his mental health history, and he never engaged with university or community mental

psychiatrysystemcommunicationsertraline
SAhospital2007-06-29

Coroner's Finding: COCKBURN Michael Philip

40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)

Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…

psychiatryemergency medicinemedicationcommunicationhaloperidol
VIC2020-09-18

Finding into death of Michael James McBain

44y · Male·Subarachnoid haemorrhage due to ruptured anterior communicating artery aneurysm

…ain medication (Lyrica/pregabalin) was appropriately weaned due to misuse history, though this caused him distress. His psychiatric and medical care were reviewed by JARO, Justice Health, and the court's HMIT. All review…

forensic medicinepsychiatrymirtazapine
NSW2020-02-13

Inquest into the death of LP

34y · Male·Foreign body aspiration

… for high-risk inmates, establishing clear guidance when assessments cannot be completed due to emotional distress, and raising awareness among custody and mental health staff about non-obvious self-harm methods. The CCT…

psychiatrycorrectional healthsystemcommunication
NSW2022-09-21

Inquest into the death of Trevor SAMUEL

35y · Male·hyponatraemia due to excessive consumption of water, against a background of psy…

…, fluid restriction, and medication adjustments. However, expert witnesses unanimously agreed that serious mental illness requires treatment in forensic hospitals rather than prison hospitals. The prison model relies on …

psychiatrycorrectional healthsystemantipsychotic medications
WA2019-12-16

Inquest into the Suspected Death of Joseph Leon PATTERSON

30y · Male·Death by drowning at sea, likely following suicide. Exact manner not determined.

…e friend John Oreo he intended to sail his yacht (the Enid) out to sea and harm himself. He was extremely distressed following the recent death of Oreo's mother, who had been a maternal figure to him. Patterson was never…

delay
QLDcommunity2021-05-07

Penno-Thompsett, Jayden Joseph

22y · Male·Exposure to the elements

…med methamphetamine heavily during a 38-39 hour road trip, had not slept for approximately 4 days, became distressed believing he had lost his drug stash, drove erratically for 5-6 hours, then abandoned the vehicle witho…

methamphetamine
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

…stralia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, personality disorder, and poly-drug abuse. On the morning of her death, she expressed suicidal id…

psychiatrygeneral practicecommunicationsystemzuclopenthixol
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

…cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 …

psychiatrycardiologycommunicationdiagnosticamisulpride
VICcommunity2014-09-01

Finding into death of Kirstan McRae-Jansen

31y · Female·plastic bag asphyxia

…se, died by plastic bag asphyxia using an LPG bottle. She was under Community Treatment Order with Eastern Health. The family alleged inadequate medication monitoring, unhelpful medications, insufficient family communica…

psychiatryolanzapine
QLDcommunity2017-05-19

Volke, Marcus Peter and Prasetyo, Mayang

27y · Male·Air embolism due to incised wound to the neck

This inquest examined the deaths of Marcus Volke (27, Australian) and Mayang Prasetyo (27, Indonesian), a couple living in Brisbane. Volke killed Prasetyo by stabbing her in the neck on 3 October 2014 following a domesti…

emergency medicineforensic medicineamitriptyline
WAhomeNew2026-05-27

Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

…bout an upcoming CTO review, he visited the car park and contemplated suicide. His support coordinator and mental health case manager visited later that morning, conducted appropriate risk assessments, and found him futu…

psychiatrygeneral practicesystemcommunicationhaloperidol
VIChospital2022-08-31

Finding into death of Cindy Jane Martin

40y · Female·Complications of WHO Class III Obesity

… for managing patients with sleep apnoea who refuse CPAP. Key learning: better integration of physical and mental health care, particularly respiratory management in patients with severe mental illness and comorbidities,…

psychiatryrespiratory medicinesystemdelaysodium valproate
SAhospital2024-09-13

Coroner's Finding: Zarrella, Dominic

88y · Male·aspiration pneumonia complicating vascular dementia and metastatic prostate canc…

…ancer, and chronic kidney disease died of aspiration pneumonia 15 days after admission to hospital under a Mental Health Act inpatient treatment order. He was admitted following refusal of food, fluids and medications. D…

oncologypsychiatry
19101118

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