Coronial

238 results for post-traumatic stress

WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…

psychiatryemergency medicinediagnosticcommunicationduloxetine
WA2025-11-28

Inquest into the Death of Cleveland Keith DODD

16y · Male·complications of ligature compression of the neck (hanging)

A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…

psychiatrypsychologyproceduralcommunication
QLDcommunity2021-08-20

Dower, Sarahjane - Non-inquest findings

26y · Female·Neck injury due to stabbing

A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…

psychologypsychiatrydiagnosticcommunicationvenlafaxine
WA2019-05-22

Inquest into the 5 Deaths in Casuarina Prison who are Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM

Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…

Five male prisoners died by suicide at Casuarina Prison, Western Australia between 2014-2015. All deaths were by hanging or self-inflicted laceration. The coroner identified multiple systemic failures including: inadequa…

psychiatrypsychologysystemcommunication
NSWaged care2022-09-28

Inquest into the death of Kerry-Ellen (Nikki) Knight

44y · Female·Hanging

…ated appropriately. Staff did not consult available electronic health records when they should have. Her distress was compounded by inability to contact family, boredom and isolation during quarantine, and being left alo…

psychiatrycorrectional healthdiagnosticcommunication
NSWhome2021-04-30

Inquest into the deaths of Gabriella THOMPSON and Tafari WALTON

27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…

Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for …

psychiatrygeneral practicecommunicationsystemmethamphetamine
NSWhospital2024-02-26

Inquest into the disappearance of Luke Huggard

31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…

A 31-year-old man with schizoaffective disorder and substance use was admitted involuntarily to the Kiloh Centre after presenting in acute psychosis with suicidal ideation on 1 April 2017. His psychotic symptoms rapidly …

psychiatrydiagnosticcommunicationlisdexamfetamine
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

Allan Kevin Hudson, a 20-year-old male with a history of depression, suicidality, substance abuse and previous sexual trauma, died by hanging on 13 August 2006 at Sir Charles Gairdner Hospital's psychiatric ward D20. He …

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
SAhome2002-11-06

Coroner's Finding: JERICHO Patricia Susanne

43y · Female·neck compression due to hanging

A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…

general practicepsychiatrycommunicationsystemaurorix
WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
WAprison2025-04-10

Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…

emergency medicineneurosurgerydiagnosticcommunicationparacetamol
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

…n staff; (5) unmanaged chronic pain from untreated shoulder injury and alcohol withdrawal contributed to distress. The coroner found the hospital's EEO assessment appropriate but criticised lack of holistic, person-centr…

psychiatryemergency medicinediagnosticcommunicationalcohol
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine
SA2019-12-20

Coroner's Finding: MORGAN Martina

60y · Female·neck compression by ligature strangulation

Martina Morgan, aged 60, died from ligature strangulation by her own leggings while in police custody at Sturt Police Station in March 2015. She was significantly intoxicated (BAC 0.23%) and taking benzodiazepines when a…

diagnosticcommunicationalcohol
NSWhome2021-04-07

Inquest into the deaths of John, Jack and Jennifer EDWARDS

Multiple gunshot wounds to the head, chest, abdomen and extremities (Jennifer); …

Two children, Jack (15) and Jennifer (13), were fatally shot by their father John Edwards at their home on 5 July 2018. John had a 35-year history of family violence across multiple relationships, with documented evidenc…

diagnosticsystem
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

Three linked suicide cases spanning February 2004 to October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital M…

psychiatrygeneral practicediagnosticcommunicationflupenthixol

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