Coronial

308 results for family crisis

SAhome2019-10-29

Coroner's Finding: LATTUCA Christophe Thomas Bruno

34y · Male·neck compression due to hanging

…e recognition that concealment of suicidal thoughts is possible, importance of collateral information from family/friends, and the challenge of predicting suicide risk in individuals who actively deny symptoms.

general practicepsychiatryalcohol
VIChome2015-05-08

Finding into death of Nilesh Sharma

36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…

…ment. Multiple healthcare professionals assessed both Mr and Ms Sharma post-collision but did not identify family violence risks or suicide risk. Cultural factors including gender role expectations, reluctance to disclos…

rehabilitation medicineneurologycommunicationsystemchloroform
VIChospital2025-07-30

Finding into death of MHT

86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…

…and declined care services. His wife suffered a stroke in July 2022, leaving him without primary care. The family sought urgent assistance from multiple services including guardianship applications, emergency services an…

emergency medicineneurosurgerysystemcommunicationondansetron
VICcommunity2017-02-20

Finding into death of Finding Peter Graham Chaucer

48y · Male·Injuries sustained when struck by a train

…uding violence, homelessness, and police involvement; and inappropriate involvement of ex-wife (subject to family violence intervention order) as carer despite safety concerns. Clinicians acted reasonably individually, b…

psychiatryemergency medicinecommunicationsystemlithium
SAcommunity2010-08-12

Coroner's Finding: BAIS Ricky James

38y · Male·ischaemic heart disease

…lled to return him but alternative approaches were not used: mental health workers, ambulance services, or family contact were not sought despite MOU requirements. Dr K. assessed Mr Bais earlier that day but did not reco…

psychiatrygeneral practicesystemcommunicationdepot zuclopenthixol
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

…en patients present with acute psychotic symptoms and elevated harm risk, not deferring for convenience or family preferences about police involvement; (2) Communication with concerned family members must clarify that cl…

psychiatryemergency medicinedelaycommunicationclozapine
QLDhome2026-02-11

Inquest into the death of FSGT

50y · Male·Gunshot wound to the head

A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…

general practicepsychologysystemcommunicationamitriptyline
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

…en the mental health team's decision to 'await recontact' rather than assertively intervene, despite clear family concerns, directly preceded his death. The coroner found that more assertive intervention by the Northern …

psychiatryemergency medicinediagnosticsystemcannabis
VICcommunity2021-11-25

Finding into death of Daniel Neil Thomas

35y · Male·Gunshot wound to the head (self-inflicted)

…n psychotic presentations, and the tension between mental health management and police safety protocols in crisis situations.

psychiatryemergency medicinesystemcommunicationmethamphetamine
NSWhospital2023-10-31

Inquest into the death of Adam Fitzpatrick

20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…

…team communication, failure to exercise clinical judgment despite clear clinical indicators, and deficient crisis resource management all contributed to this preventable death.

intensive careanaesthesiadiagnosticproceduralrocuronium
SAhome2019-08-14

Coroner's Finding: KUSKOFF Alexander Peter

50y · Male·gunshot wounds to chest and abdomen

…Kuskoff, aged 50, was fatally shot by STAR Group officer DA on 16 September 2015 following a mental health crisis. Kuskoff displayed florid psychotic symptoms including paranoid delusions, was heavily armed, and fired mu…

psychiatryemergency medicinecommunicationsystem
VIChome2023

Finding into death of Mr ZJF

27y · Male·Dextromethorphan toxicity

Mr ZJF, a 27-year-old man with a longstanding history of schizophrenia, polysubstance use disorder, and depression, died from dextromethorphan toxicity. He was subject to a Community Treatment Order at the time of death …

psychiatrygeneral practicesystemdextromethorphan
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

…arbitone from Mexico via internet, which her partner had previously confiscated. She had new financial and family stressors, and had made a new will days before death benefiting her partner. The coroner recorded an open …

psychiatrypsychologysystemproceduralpentobarbitone
VIChome2020-09-11

Finding into death of Mr A

44y · Male·compression of the neck consequent upon hanging

… risk assessment and mental health monitoring; general practitioners are crucial contact points for men in crisis who rarely access specialist mental health services; substance use assessment and treatment must be integr…

general practicepsychiatrysystemdelayalcohol
VIChome2023-01-23

Finding into death of Cody Morrella Watson

19y · Female·Hanging

Cody Watson, 19, died by hanging following childhood sexual abuse, family violence, and inadequate trauma-informed care. She disclosed abuse at 15, subsequently developing borderli…

general practicepsychiatrysystemdelayvenlafaxine
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…ar-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania and psychosis…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWhospital2023-09-11

Inquest into the death of TE

26y · Female·multiple blunt force injuries from fall from height; significant contributing co…

A 26-year-old woman with severe borderline personality disorder died by suicide following a fall from cliffs. She presented to hospital after a serious suicide attempt earlier the same day. Expert evidence indicates she …

psychiatryemergency medicinediagnosticcommunicationpregabalin
NSWhome2024-04-05

Inquest into the death of Todd McKenzie

40y · Male·gunshot wounds

…ed to produce violent confrontation. Critical clinical lessons include: early mental health assessment and family consultation were inadequate; a consultant psychiatrist should have been engaged; less-lethal options were…

psychiatryforensic medicinediagnosticcommunication
VIChospital2016-08-22

Finding into death of Alison Rae Wolinski

36y · Female·Hanging

…ure to involve her father despite his concerns; and unclear follow-up arrangements. Earlier involvement of family, more conservative discharge planning, and clearer community coordination might have altered the outcome.

psychiatryemergency medicinecommunicationsystemvenlafaxine
WAhospital2024-04-08

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

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

…it. Critical gaps were identified: the Department of Communities failed to adequately assess referrals for family support services and delayed action; Bentley Family Clinic provided appropriate community care despite fra…

psychiatryemergency medicinesystemdelaysertraline
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