259 results for “suicidal intent”
28y · Male·Global cerebral ischaemic injury due to hanging
…ng points. The coroner found risk assessments were reasonable given his assurances of safety and denial of intent, though noting the difficulty of predicting suicide risk. The coroner acknowledged the cell lacked safety …
47y · Female·Overdose of hydromorphone
A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history …
33y · Male·Mixed drug toxicity
… shortly after release from prison, during separation from his daughters and amid financial stress. While suicidal intent cannot be definitively established, the coroner found the police investigation inadequate. Critica…
39y · Male·ligature compression of the neck (hanging)
…tients relocate frequently between service areas. Although the deceased masked severe symptoms and denied suicidal intent, earlier hospital assessment after the arrest might have provided opportunity for intervention. Ho…
53y · Male·neck compression due to hanging
…ough he presented as deeply unhappy and was on the high-risk assessment team list, he consistently denied suicidal intent. A chaplain raised serious safety concerns after an emotionally distressing incident in December 2…
30y · Male·ligature compression of the neck (hanging)
…icide attempts, or specific hanging plans), allowing him to close his cell door while alone despite known suicidal intent, and failure to have enough safe cells at the facility. The coroner found the lack of supervision …
19y · Male·complications of ligature compression of the neck
…sessment Group) did not access recordings of his phone calls from 4-8 July 2020 where he explicitly stated intent to harm himself and disclosed active self-harm; (2) staff were unaware of his deteriorating mental state a…
50y · Male·ligature compression of the neck (hanging)
…rest' for follow-up monitoring. After his court appearance, he made a phone call to his father indicating suicidal intent, then fashioned a ligature in his cell. Clinical lessons include the importance of identifying and…
74y · Female·Multiple injuries sustained when struck by train
…had been on extended psychiatric admission and transferred to transitional care, where she became acutely suicidal. In the ED, she was appropriately assessed as requiring admission under the Mental Health Act but inadequ…
41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity
… review (best practice every 18 months) and potential Schedule 8 permit compliance issues. No evidence of suicidal intent. Death likely accidental overdose. Case illustrates systemic challenges in managing complex polyph…
62y · Female·Hypoxic brain injury complicating mixed drug toxicity
Evelyn Faye Scherger (62F) died from hypoxic brain injury following a polypharmacy overdose on 6 September 2011, two days after discharge from the Mildura Base Hospital Emergency Department. She had presented after a sus…
36y · Male·Hanging
…alth assessments (within 3 days) had classified him as low suicide risk (S4, P3 ratings). While he denied suicidal intent and recent psychiatric reviews were appropriate, the coroner identified documentation gaps regardi…
19y · Male·Hanging
…, died by hanging in Townsville Correctional Centre on 26 December 2015. Despite documented self-harm and suicidal ideation as a juvenile, no Self-Harm Episode History flag was raised at adult prison intake, and he was n…
Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…
…inadequate monitoring during escort. Michael and Mitchell's deaths were not preventable—Michael concealed suicidal intent from all staff, and Mitchell's cardiac event was unexpected in a young healthy-appearing prisoner.…
29y · Male·mixed drug toxicity including heroin
…ssessment following drug discovery, and staff training on overdose recognition, though unable to determine intent.
53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exs…
Jacob Carr died from a gunshot wound to his left thigh sustained during a police operation at his home. He had assaulted his elderly mother, and police responded to a domestic violence call. During confrontation, Mr Carr…
62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …
…she must be admitted to G Ward first. Dr L. reassessed her at 2pm, found her calmer and without expressed suicidal intent, and rescinded the Form 1 and discharged her. The coroner found his reassessment decision reasonab…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
31y · Male·hanging (self-inflicted)
…de risk factors. The coroner found multiple contributing failures: inadequate mental health screening for suicidal ideation, poor communication between health and corrections staff, insufficient camera surveillance of th…
24y · Male·Gunshot wound to the head
A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…
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