Coronial

475 results for psychiatric admission

VICmental health2014-09-29

Finding into death of Kelvin Robert Davidson

75y · Male·Hanging

Kelvin Davidson, a 75-year-old man with complex psychiatric history including prior self-harm and attempted hanging, was admitted to Baringa Aged Psychiatric Unit …

psychiatrysystemcommunicationtemazepam
SAhospital2019-04-15

Coroner's Finding: CURTIN Roger

63y · Male·metastatic non-small cell lung carcinoma with chronic obstructive lung disease

…m natural causes. The case illustrates managing delirium in terminal cancer complicated by pre-existing psychiatric illness and the appropriate use of sedation in end-of-life care when behaviour becomes unmanageable des…

palliative carepsychiatryolanzapine
VIChome2024-06-11

Finding into death of Martin Page

39y · Male·most likely suicide; possibly accidental death from untreated epilepsy or natura…

… mental health monitoring in vulnerable individuals expressing suicidal ideation, management of complex psychiatric and neurological comorbidities, ensuring medication compliance in epilepsy patients, and police respons…

psychiatryneurologysystemdelay
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
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

…conded from his supported residential service and was found deceased. The coroner found Austin Health's psychiatric assessment and management suboptimal, highlighting failures to: utilise relapse prevention plans, antic…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
VICmental health2017-11-14

Finding into death of Sandra Michelle Liddy

44y · Female·Heroin toxicity

…iddy, aged 44, died from heroin toxicity while on unescorted day leave from an involuntary mental health admission. She had a 25-year psychiatric history with paranoid schizophrenia and polysubstance use disorder but ha…

psychiatryemergency medicineheroin
NSWhospital2014-08-22

Inquest into the death of Alana GOLDSMITH

21y · Female·Multiple injuries sustained from being struck by a train; death by suicide while…

…to her decision. The case highlights the difficulty in predicting suicide and the need for comprehensive admission protocols, continuity of care, and improved supervision procedures in eating disorder units.

psychiatrygeneral practicecommunicationsystemolanzapine
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
SAhospital2019-03-25

Coroner's Finding: NICHOLSON James

65y · Male·hypoxic ischaemic encephalopathy complicating hanging

…he next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included: misdiagnosis of the underlying steroid-induced syndrome, failure to…

oncologypsychiatrydiagnosticcommunicationdexamethasone
WAhome2021-03-25

Inquest into the Death of FJ (Name Subject to Suppression Order)

35y · Female·multiple injuries sustained in fall from sixth-floor balcony

… at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during transitions between healthcare systems—FJ lost access to private psychiatry when leaving im…

psychiatrygeneral practicecommunicationsystemlithium
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappe…

psychiatryemergency medicinecommunicationdiagnosticantidepressants
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
TASmental health2016-01-29

Coroner's Finding: Mr D

57y · Male·Multiple fatal injuries following a fall from height onto rocks

…y of mental illness and suicide. After a previous suicide attempt by asphyxiation, he was admitted to a psychiatric inpatient unit for assessment and treated with antidepressants and anxiolytics. He was discharged after…

psychiatrygeneral practicecommunicationsystemescitalopram
TASmental health2016-10-07

Coroner's Finding: Weily, Richard Maurice

85y · Male·Probable pneumonia following a hip fracture (comminuted fracture of right acetab…

…(RFC) mental health facility on 13 June 2013 under Mental Health Act provisions for management of acute psychiatric symptoms including agitation, confusion, and suicidal ideation. While at RFC, he fell from bed on 7 Jul…

general practicegeriatric medicinesystemdelayamiodarone
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
SAhospital2020-07-02

Coroner's Finding: WHATLEY Deborah Rose

55y · Female·ischaemic heart disease complicated by epilepsy, asthma and schizophrenia

…nd discharged her. She returned the next day with worsening psychotic symptoms and was admitted under a psychiatric treatment order. On the morning of admission, she deteriorated with altered consciousness and was trans…

emergency medicinepsychiatryclozapine
VIC2013-11-25

Finding into death of Rahul Prasad

28y · Male·Global cerebral ischaemic injury due to hanging

…k, was discharged from the Acute Assessment Unit on 7 May 2010 with an S3 (potential) risk rating after psychiatric assessment. Despite subsequent reports of command hallucinations telling him to self-harm on 6, 7, and …

psychiatryintensive carediagnosticcommunication
WAcommunity

Inquest into the Death of Gary John LYDDIETH

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

…year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prior su…

psychiatrygeneral medicinesystemcommunication
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

…ne) in the presence of advanced emphysema and acute bronchopneumonia. He was admitted to Spencer Clinic psychiatric inpatient unit following an assault on staff at Karingal nursing home. During his 23-hour hospital admi…

psychiatryemergency medicinemedicationdiagnosticclozapine
VICmental health2019-09-19

Finding into death of Vanna Vassallo

68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall

…rrhage sustained in a fall at an aged mental health inpatient unit. She had sustained three falls during admission, with the final unwitnessed fall on 14 May 2017 resulting in massive intracranial bleeding. Clinical ass…

psychiatrygeriatric medicinepossibly_preventablefluphenazine decanoate
110111224

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