Coronial

304 results for chronic suicide risk

VIChospital2015-08-28

Finding into death of Moufid Sawan

61y · Male·Complications of cutaneous burns

A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary …

psychiatryemergency medicinecommunicationdiagnosticrisperidone
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

…smania. Mason was intoxicated, had a long history of violent offending and mental health issues including chronic suicidality precipitated by relationship breakdown. Police were called after he assaulted family members,…

general practiceemergency medicinesystemalcohol
SAmental health2005-01-27

Coroner's Finding: ROBJOHNS Ronald Thomas

89y · Male·congestive cardiac failure due to ischaemic heart disease and aortic valve steno…

…s appropriate psychiatric assessment and involuntary admission for a severely depressed elderly man at high risk of suicide and self-neglect, with death ultimately from natural cardiac causes.

psychiatrygeriatric medicinesertraline
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

FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of ps…

psychiatrygeneral practicecommunicationsystemlithium
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

…te 55 self-harm incidents between January and April 2019, Callum was reduced from high to moderate ARMS (At Risk Management System) on 17 April 2019 following a PRAG meeting where he appeared settled. He was then placed …

psychiatrycorrectional healthsystemcommunicationtramadol
VICcommunity2021-11-25

Finding into death of Daniel Neil Thomas

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

…linical lessons include: managing disengaged voluntary mental health patients post-discharge, recognising suicide risk in psychotic presentations, and the tension between mental health management and police safety proto…

psychiatryemergency medicinesystemcommunicationmethamphetamine
SAcommunity2005-03-14

Coroner's Finding: Cooper Kunmanara

Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…

Four separate inquests into the deaths of Kunmanara Ward (19), Kunmanara Ken (35), Kunmanara Ryan (25), and Kunmanara Cooper (27) on the Anangu Pitjantjatjara Lands between May 2003 and March 2004. Three deaths were by h…

psychiatrygeneral practicedelaycommunicationpetrol
QLD2013-12-11

Woods, Gavin Lyle

46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)

A 46-year-old teacher, Gavin Lyle Woods, died by suicide after prolonged workplace stress and an undertreated major depressive disorder. He had been a deputy prin…

psychiatrygeneral practicecommunicationsystemescitalopram
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient …

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
WAAugust 2024

Inquest into the Death of Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

…tthew Francis Leach, a 50-year-old man with longstanding alcohol dependence, depression, and a history of suicide attempts, died by ligature hanging in his cell at Hakea Prison shortly after being sentenced to 12 months…

psychiatrypsychologysystemdelayvenlafaxine
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical f…

psychiatryemergency medicinediagnosticcommunicationantidepressants
TAScommunity2019-09-09

Coroner's Finding: Wilson, Jacob Leigh

27y · Male·chest and abdominal injuries from single motorcycle crash

Jacob Wilson, aged 27, died from chest and abdominal injuries sustained in a motorcycle crash on 22 January 2018. He was travelling to a scheduled mental health appointment when he lost control of his motorcycle on a cur…

general practicepsychiatrycommunicationdiazepam
SA2015-06-11

Coroner's Finding: PAYNE Mark William

28y · Male·neck compression due to hanging

…senior management. Key clinical lessons: senior staff failed to ensure proper monitoring protocols for high-risk suicide prevention; a cost-driven approach replaced proven gold-standard observation; and institutional dys…

correctional healthpsychiatrysystemcommunication
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

…cols, and included an unsuitable co-resident. Key clinical failures included: insufficient recognition of chronic suicide risk, poor medication compliance without enforcement mechanisms, missed opportunities for crisis …

psychiatryemergency medicinediagnosticcommunicationcitalopram
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflict…

psychiatrygeneral practicediagnosticcommunication
QLD2019-05-08

Appleton, Garry Ronald

48y · Male·Hypovolaemic shock due to incised wounds to the arms; other significant conditio…

…rison-issue razor blade while in custody at Brisbane Correctional Centre in May 2015. Initial mental health risk assessment on admission was adequate, but critical failures occurred: the psychologist did not access infor…

psychiatrypsychologycommunicationsystem
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

…clinical lessons include: (1) improved handover communication between crisis teams and day staff after high-risk calls is essential—Ms S disclosed a medication stockpile and suicidal ideation on 10 May but this was not f…

psychiatrygeneral practicecommunicationsystemphentermine
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

…clan Brennan, a 38-year-old sentenced prisoner at Acacia Prison due for release on 30 April 2008, died by suicide on 27 April 2008 from exsanguination due to penetrating wounds to his arm veins. Brennan had a long-stand…

psychiatrycorrectional healthsystemdelaylithium
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…

…eaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked to petrol sniffing (chronic substance abuse causing severe neurological damage), mental health issues, and systemic service failures.…

psychiatryemergency medicinesystemdelaypetrol
NSWcommunity2018-04-30

Inquest into the death of Tahlia Peden

17y · Female·Hanging

Tahlia Peden, a 17-year-old Ngunnawal woman, died by hanging ten days after being sexually assaulted. She was assessed by Wagga Sexual Assault Service but a critical breakdown in the referral pathway meant Goulburn SAS n…

psychiatryemergency medicinecommunicationsystem
112131416

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