Coronial

390 results for mental health deterioration

SAhospital2022-08-15

Coroner's Finding: Kelley, John Michael

83y · Male·General inanition and aspiration pneumonia on a background of end-stage Alzheime…

…ith end-stage Alzheimer's dementia died from general inanition and aspiration pneumonia while subject to a Mental Health Act order in hospital. He had experienced two episodes of aspiration pneumonia during his admission…

psychiatrygeriatric medicineantibiotics
QLDcommunity2015-12-14

Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra

42y · Male·Anthony Young: multiple gunshot wounds to the body and arm; David Young: multipl…

…t by police after fatally stabbing his brother David and David's partner Louise. Anthony had deteriorating mental health including paranoia, substance use, and lack of psychiatric engagement despite family attempts to ob…

psychiatryforensic medicinediazepam
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
SAhospital2011-09-20

Coroner's Finding: BELLOCCO (aka Ieva) Carmelina

61y · Female·respiratory failure secondary to advanced malignancy

…ate, and no recommendations were made. Clinical lesson: managing cancer treatment refusal in patients with mental illness requires careful capacity assessment, family consultation, and willingness to shift to palliative …

oncologycolorectal surgery
VIChome2026-04-14

Finding into death of Justin James Filardo

45y · Male·Gunshot wounds to the head and left shoulder

…eks prior, Justin had ceased his clozapine medication without clinical knowledge, leading to psychotic deterioration. On 30 July 2025, he attacked Bianca causing severe arm trauma. Police deployed tasers twice but Justi…

psychiatrygeneral practicesystemdelayclozapine
VIChome2020-06-15

Finding into death of Gordon Malcolm Wallace

71y · Male·Plastic bag asphyxia and argon gas inhalation

…acity and clear intent. Key clinical lessons: recognize when cumulative medical burden and progressive deterioration significantly impact psychological wellbeing; document discussions about end-of-life wishes thoroughly…

nephrologyoncologysystemargon gas
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

34y · Female·not able to be determined - body not found

…ons related to poor medication compliance. Despite recent improvement during hospitalisation and community mental health follow-up, Sana travelled to North Head on 1 September and was last seen on CCTV at 1:01pm walking …

psychiatrysystemcommunicationclozapine
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

…topsy. The coroner identified that while his psychiatric care was appropriate, better coordination between mental and physical health services, ongoing cardiovascular risk assessment, and implementation of pulse oximetry…

psychiatrycardiologysystemcommunicationquetiapine
VIC2015-11-05

Finding into death of Kasim Colic

79y · Male·Unascertained

…disease, and a history of violent behaviour was placed under a non-custodial supervision order following a mental impairment finding. Approved leave to visit family in Bosnia Herzegovina in February 2014 was extended whe…

psychiatrygeriatric medicinecommunicationsystem
VIChospital2024-11-13

Finding into death of Louise Spencer

58y · Female·Alzheimer's Dementia on a background of Trisomy 21

…rome and Alzheimer's dementia, died of natural causes at Austin Hospital following admission for rapid deterioration post-COVID-19 infection. She was transferred to the Palliative Care Unit after consultation with her f…

palliative carerespiratory medicine
WAcommunity2026-03-13

Inquest into the Suspected Death of PARBHAT

24y · Male·unknown cause

Parbhat was a 24-year-old Indian international student and worker who disappeared at The Gap in Torndirrup National Park, Albany, WA on 5 August 2024. After moving to Perth in 2021, his circumstances deteriorated followi…

alcohol
VICmental health2014-12-23

Finding into death of David John McLeod

58y · Male·Cardiomegaly and severe single vessel coronary artery atherosclerosis in a man w…

…an with schizoaffective disorder, was admitted to a psychiatric inpatient unit on 21 August 2012 following mental health deterioration. He presented with signs of infection, received appropriate clinical assessment and i…

psychiatrygeneral medicinerisperidone
VIChospital2024-12-02

Finding into death of S K

25y · Male·Gunshot injury to the head

…volver under the influence of amphetamines, cannabis, benzodiazepines and other drugs. SK had engaged with mental health services following a suicide attempt in June 2021 and was referred to substance abuse treatment ser…

emergency medicinepsychiatrysystemdelaymethamphetamine
TAScommunity2021-01-25

Coroner's Finding: Townsend, David Lester

69y · Male·Partial contact range gunshot wound of the head

…eptember 2017. He had been receiving psychiatric care from Dr McDougall and case management from community mental health services. Following a July 2017 hospitalisation for acute depression and suicidality related to an …

psychiatrygeneral practice
WAhome2025-01-23

Inquest into the Suspected Death of Benjamin Jacob VAN TRIGT

38y · Male·electrical injury

…requiring hospitalization, with the most recent admission ending 4 October 2022. Despite regular community mental health follow-up including depot antipsychotic medication, weekly appointments, and crisis pathway educati…

psychiatryemergency medicinepaliperidone
QLD2012-08-07

Bucknall, David John

41y · Male·Hanging

…l and received psychiatric care after referral, though there was a two-month delay in accessing the Prison Mental Health Service due to resource limitations. His psychiatrist provided good care and found no evidence of a…

psychiatrygeneral practicesystemdelaymirtazapine
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

…y and wellbeing. The coroner emphasised systemic issues: lack of facilities for young people with combined mental illness and brain injury, funding constraints, and inter-agency responsibility gaps between mental health

psychiatrygeneral medicinesystemdelaylithium
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

…s were used. Forensicare subsequently implemented significant improvements including standardised physical health monitoring systems, mandatory use of observation charts during seclusion, clearer escalation pathways, and…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
NSWhome2017-11-16

Inquest into the death of Sandra Deacon

59y · Female·blunt force head trauma

…SW. This was a homicide case. Key clinical and systemic issues identified include: Weigand's deteriorating mental health (paranoid ideation, erratic behaviour) documented following April 2014 hospitalisation at Wyong Hos…

forensic medicinepsychiatrysystemantipsychotic medication
VICmental health2022-12-13

Finding into death of Jamie Andrew Kowalewsky

27y · Male·Global cerebral ischaemic injury in the setting of hanging

Jamie Kowalewsky, a 27-year-old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide attempt, was …

psychiatryintensive carecommunicationlorazepam
111121320

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