Coronial

308 results for family crisis

SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

… concerning statements as manipulation; understanding the obligation to breach confidentiality and contact family when a minor presents with acute psychiatric symptoms; and establishing clear referral pathways to emergen…

psychologypsychiatrydiagnosticcommunication
VIChome2024-04-15

Finding into death of Craig Geoffrey Rickard

55y · Male·Hanging

…rections case manager on 7 January 2020. A risk management plan was implemented including GP notification, crisis team contact details, and advice to attend ED if deteriorating. The coroner found his suicide was likely i…

psychiatryemergency medicinesystemcommunicationfluoxetine
WAcommunity2021-03-25

Inquest into the Suspected Death of Jason Marcus LAWSON

32y · Male·unascertained; most likely exposure after walking in bushland

…h-risk patients, timely escalation of concerns when appointments are missed (counsellor delayed contacting family after first missed appointment), and consideration of immediate environmental risks in acutely suicidal in…

psychiatrypsychologycommunicationdelaycitalopram
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

…k injury while being restrained by police. Clinical lessons emerged regarding mental health assessment and crisis response. On 5 August, psychiatric assessment in ED correctly followed the Mental Health Act in declining …

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2018-09-10

Inquest into the Death of Theodore Herbert Eric JOHANSEN

50y · Male·Drowning

…t. The ED doctor referred him to a psychiatric liaison nurse, who assessed him as low risk after he denied family history of mental illness and suicide, appeared calm and composed, and stated he no longer felt suicidal. …

psychiatryemergency medicinediagnosticcommunicationamitriptyline
WAcommunity2016-03-18

Inquest into the Death of David Davidson LAWSON

41y · Male·unascertained

…gical state likely preventing self-care and survival planning, and absence of any contact with services or family afterwards. The cause of death remains unascertained; likely possibilities include dehydration, self-harm …

psychiatryemergency medicinesystemcommunicationolanzapine
QLD2006-06-08

Hewson, Jamie

36y · Male·gunshot wounds to the head and pelvis

Jamie Hewson, a 36-year-old farmer, was killed by police gunshot wounds following an 18-hour siege at his family farm. After allegedly threatening a neighbour with a rifle, a police response escalated from negotiators t…

emergency medicineforensic medicinecommunicationprocedural
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

…nt. He denied suicidal ideation but was discharged home without documented risk management discussion with family. Key failures: inadequate collateral history-gathering, no formal capacity assessment, lack of face-to-fac…

psychiatryemergency medicinediagnosticcommunicationquetiapine
WAcommunity

Inquest into the Death of Gary John LYDDIETH

54y · Male·Unknown - death established on balance of probabilities but manner and cause und…

…014 while remaining at "very high chronic suicide risk." He had multiple prior suicide attempts and severe family conflict. Despite psychiatric assessment that he was "well" at discharge and future-planning, he was disch…

psychiatrygeneral medicinesystemcommunication
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental …

general practicepsychiatrydiagnosticcommunicationfluoxetine
ACTcommunity2020-09-25

Inquest into the death of ANTHONY ROMANAS CARISTO

54y · Male·Cardiac arrest in a person with cardiac hypertrophy and generalised atherosclero…

… died from cardiac arrest on 31 October 2017 following police deployment of a taser during a mental health crisis. He had consumed a lethal dose of methamphetamine, was actively self-harming with knives, and exhibited ps…

emergency medicineparamedicinedelaysystemmethamphetamine
VIChome2015-05-08

Finding into death of Divya Sharma

3y · Female·Homicide by chloroform exposure and/or smothering by father

Divya Sharma, age 3, died in April 2012 in Glen Waverley, Victoria, as part of a family homicide-suicide perpetrated by her father. The coroner found she was likely killed by chloroform exposure…

rehabilitation medicineneurologydiagnosticcommunicationchloroform
WAhome2023-07-14

Inquest into the Death of Matthew James WORTHINGTON

Male·Gunshot injury to the head

Matthew Worthington died from a self-inflicted gunshot wound to the head during a 21-hour police siege at his home in Bayswater, Western Australia, on 24 November 2020. He was experiencing a relationship breakdown, had r…

emergency medicineintensive caremethamphetamine
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

…ic admission. She had presented to emergency with acute suicidality on 18 June, attended police station in crisis on 21 June, and was admitted on 21 June via Section 10 Mental Health Act order. Despite expressing repeate…

psychiatryemergency medicinecommunicationsystemquetiapine
SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…

general practiceemergency medicinediagnosticproceduralparacetamol
SAhome2020-12-07

Coroner's Finding: ROBERTS Paul Scott

38y · Male·combined effects of inhalation of products of combustion and incineration

Paul Scott Roberts, aged 38, died from incineration and inhalation of combustion products after setting himself alight during police attendance at his home on home detention bail. He had a history of chronic dysthymia, a…

communicationalcohol
VIC2023-11-16

Finding into death of John Doe

33y · Male·Contact range shotgun injury to the head

A 33-year-old man died from a contact range shotgun injury to the head while subject to a Mental Health Act apprehension order. Police conducted a six-hour operation involving 120 members across multiple units after he p…

communicationsystemmethamphetamine
VIChomeNew2026-06-24

Finding into death of Sheridan Louise Burnell

24y · Female·Mixed drug toxicity

…Her friends managed her medications responsibly until she unexpectedly accessed the hidden supply during a crisis. No clinical errors in psychiatric care were identified, and Ambulance Victoria subsequently updated escal…

psychiatrygeneral practicecommunicationsertraline
NSWhospital2014-12-19

Inquest into the death of JX

32y · Male·multiple injuries sustained in a fall from height

…a cliff while experiencing an acute psychotic relapse. The case reveals critical failings in mental health crisis response. When a psychologist appropriately recognised the patient's psychosis and called the Mental Healt…

psychiatrypsychologycommunicationsystemvenlafaxine
NSWcommunity2021-10-22

Inquest into the death of Liselle HOUBERT

23y · Female·Multiple injuries received in a deliberate motor vehicle collision

Liselle Houbert, 23, died in a deliberate head-on motor vehicle collision caused by her partner Joshua Booth on 28 May 2020. Booth had been experiencing significant mental health issues including depression, PTSD, anxiet…

psychiatrygeneral practiceantidepressant medications
110111216

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