Coronial

366 results for psychiatric admission assessment

VIChome

Finding into death of Jarrad John Ford

24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs

…al health triage service; the practitioner advised half-hourly observations at home rather than hospital admission. The mother fell asleep at 3:30am after conducting checks. The deceased was found unresponsive at 5:00am…

psychiatryemergency medicinediagnosticsystemdiazepam
VICmental health2018-05-17

Finding into death of Lucas Richard Towndrow

51y · Male·Injuries sustained in a train incident

Lucas Towndrow, a 51-year-old involuntary psychiatric patient at Latrobe Regional Hospital, died by suicide on a railway track on 13 December 2016 after bein…

psychiatrydiagnosticcommunication
VIChome2021-07-14

Finding into death of Edward Michael Espino

36y · Male·neck compression in the circumstances of hanging

…tacted police and mental health services expressing distress but denying suicidal intent. NWMHS Triage's assessment was appropriate and psychiatric admission was not clinically indicated. The coroner found no causal conn…

psychiatryforensic medicinesystemsodium valproate
VICmental health

Finding into death of GM

52y · Male·Unascertained

…utside despite guideline recommendations that newly admitted patients should not be granted leave until psychiatric assessment. After displaying elevated mood with 'grand plans' to drive to Cairns, he was appropriately …

psychiatryemergency medicinesystemcommunicationpholcodine
VICmental health2019-05-17

Finding into death of Thi Ha Do

42y · Female·Incised injury to the neck

… woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Clinical manage…

psychiatryforensic medicinesystemcommunicationmirtazapine
VIC2011-10-20

Finding into death of Jeremy Edward Chandler

49y · Male·Acute blood loss from a single incised injury to left forearm

Jeremy Edward Chandler, a 49-year-old first-time prisoner, died by suicide in Melbourne Assessment Prison 36 hours after admission. He had been convicted of serious charges and remanded in custody pendin…

psychiatrycorrectional healthdiagnosticcommunication
QLDmental health2006-11-31

Jeffrey, Helen

38y · Female·Asphyxiation by plastic bag

…ied by asphyxiation using a plastic bag in Ward GE of Nambour Hospital on 24 March 2005, five days after admission for psychiatric care following a suicide attempt. The coroner found no criminal culpability. Key clinica…

psychiatryemergency medicinesystemcommunication
VICcommunity2025-04-16

Finding into death of Jamie Peter Nisbet

47y · Male·Compression of the neck arising from hanging

…iatry registrar Dr D. on 19 September, she concluded his presentation was non-genuine and he was seeking admission to avoid court. He was not admitted. Following a failed telehealth appointment on 20 September where he …

psychiatryemergency medicinecommunicationsystemrisperidone
NSWmental health2023-12-15

Inquest into the death of CC

33y · Male·Hanging

…ital on 7 June 2022 under involuntary mental health detention. Over eight days, he received appropriate psychiatric care including antipsychotics, mood stabilisers and benzodiazepines at observation level 3 (30-minute o…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
SAhome2025-03-07

Coroner's Finding: Bombardieri, Mark

32y · Male·Gunshot wound to the head

…ith a complex history of criminal behaviour, mental health disorders, polysubstance abuse, and multiple psychiatric admissions, died by suicide on 6 March 2019 via self-inflicted gunshot wound using a rifle stolen from …

communicationmethamphetamine
SAmental health2020-12-15

Coroner's Finding: BARTON Stephen John

43y · Male·blunt neck trauma from compression of the neck

Stephen John Barton, aged 43, died from blunt neck trauma inflicted by roommate Lindon Sekrst in a psychiatric ward. Both were detained patients under Mental Health Act orders. Sekrst, a 23-year-old with paranoid i…

psychiatryemergency medicinediagnosticsystemrisperidone
VICcommunity2017-08-25

Finding into death of Steven John Dows

43y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…his case highlights the complexity of determining causation when mental health conditions, uncontrolled psychiatric illness, and potential medical factors may all contribute to tragic outcomes.

forensic medicinepsychiatry
NSW2022-02-09

Inquest into the death of IM

37y · Male·Sharp force injuries of the neck and left arm

…deation on each occasion. Critical information emerged post-mortem: his former spouse disclosed a prior psychiatric admission in March 2017, ongoing private psychotherapy, and medication non-compliance associated with s…

forensic medicinepsychiatrycommunication
SAhospital2011-11-03

Coroner's Finding: BALLARD Margaret Dawn

76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction …

A 76-year-old woman with Alzheimer's dementia and psychiatric illness collapsed on 1 January 2009 and was assessed in the Emergency Department. Dr B. diagnosed vasov…

emergency medicinepsychiatrydiagnosticcommunicationsodium valproate
QLDmental health2006-09-08

Robinson, Terence James

54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus

… he developed profound sedation and neurological deterioration. Critical issues included: lack of daily psychiatric review in the Special Care Unit (he was not seen on day 3 post-sedation); delayed recognition of seriou…

psychiatryneurologydiagnosticcommunicationparoxetine
NSWmental health2015-07-14

Inquest into the death of DA

34y · Male·Neck compression due to hanging

… on addiction alone; (2) conversion from involuntary to voluntary status on day 1 lacked documented risk assessment and consultant psychiatrist input; (3) discharge on day 2 occurred without face-to-face assessment by th…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
SA2000-12-04

Coroner's Finding: NOBELS Laurens Adrian Keith

29y · Male·hanging

A 29-year-old man remanded in custody at Adelaide Remand Centre died by hanging on 15 January 2000. At admission, he denied self-harm risk and psychiatric history; no warning signs were identified. He was found hangin…

forensic medicineemergency medicinecommunicationsystem
VIChome2023-06-06

Finding into death of Michael Stephen Delaney

37y · Male·Plastic bag asphyxia

… between treating psychiatrists and inpatient mental health facilities when patients are assessed during admission, particularly regarding treatment recommendations; (2) clarify responsibility for referrals between serv…

psychiatrycommunicationsystemdiazepam
NTmental health2019-09-13

Inquest into the death of Daniel Alexander Bleaney

37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof

…ttempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, following assessment in the ED. He was assessed as highest risk for suicide but placed on 15-minu…

psychiatryemergency medicinesystemdiagnosticdiazepam
WAmental health2024-03-07

Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

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

…etya, a 41-year-old Bulgarian-born woman, died by ligature compression of the neck while an involuntary psychiatric patient at Bentley Health Service Ward 6 on 16 December 2020. She had been admitted following acute psy…

psychiatrydiagnosticcommunicationescitalopram
19101119

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