Coronial

273 results for depressive disorder

SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
ACT2023-02-10

Inquest into the death of Joshua

18y · Male·asphyxia by hanging; intentional self-harm

Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…

psychiatryemergency medicinecommunicationsystemsertraline
VICprison2014-01-24

Finding into death of Adam Sasha Omerovic

40y · Male·Ligature compression of the neck in circumstances of being hanged

Adam Omerovic, a 40-year-old man with a long history of depression, substance abuse, and prior suicide attempts, died by hanging in a Melbourne Assessment Prison cell on 23 March 2010. He had been remanded on armed robbe…

psychiatrycorrectional healthdiagnosticsystemescitalopram
VIC2024

Finding into death of W B

59y · Male·Gunshot wound of head

A 59-year-old police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP ma…

general practicepsychiatrycommunicationsystemdiazepam
QLDhospital2017-09-07

Mr R - Non-inquest findings

63y · Male·Multiple injuries due to fall from height

A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…

neurosurgeryneurologysystemcommunicationcitalopram
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
NSW2020-02-13

Inquest into the death of LP

34y · Male·Foreign body aspiration

A 34-year-old man died by foreign body aspiration while in custody at a correctional centre, three days after arrest for a serious violent crime. He fashioned an airway obstruction from toilet paper and meal pack plastic…

psychiatrycorrectional healthsystemcommunication
NSWhospital2025-02-17

Inquest into the death of IE

27y · Male·Multiple blunt force injuries from jumping off a cliff

A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…

psychiatryemergency medicinediagnosticcommunicationvenlafaxine
VIC2017-08-01

Finding into death of Maria Liordos

16y · Female·Mixed drug toxicity

Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…

paediatricspsychiatrycommunicationsystemheroin
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
QLDmental health2015-06-10

McDonnell, Kevin Joseph John

80y · Male·Drowning

An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…

psychiatryemergency medicinedocumentationcommunicationolanzapine
VICmental health2017-02-07

Finding into death of Esther Ng Kit Ching

53y · Female·Hypoxic brain injury due to hanging

A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her deat…

psychiatrycommunicationdelaymirtazapine
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that day (5 June) after …

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
WA2013-05-30

Inquest into the Death of Mcdonald, Charles Edward

38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia

A 38-year-old remand prisoner with schizophrenia on clozapine died suddenly in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to prison on 20 Jul…

psychiatrypharmacologycommunicationsystemclozapine
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

…l deficiencies were identified in post-stroke mental health care: there was no routine screening for mood disorders using validated tools during rehabilitation or in community follow-up, despite clinical guidelines recom…

neurologyrehabilitation medicinediagnosticsystem
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…

general practicepsychiatrydiagnosticcommunicationfluoxetine
NSWmental health2019-11-29

Inquest into the death of Harold EDWARDS (a pseudonym)

49y · Male·Hanging

A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …

psychiatrydiagnosticcommunicationtemazepam
SAcommunity2005-03-14

Coroner's Finding: Ward Kunmanara

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

Four Anangu (Aboriginal) young men died between May 2003 and March 2004 on the Anangu Pitjantjatjara Lands in South Australia. Three deaths were by hanging (ages 19, 25, 27); one by exposure (age 35). Deaths were linked …

psychiatryemergency medicinesystemdelaypetrol
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
WAmental health2024-03-07

Inquest into the Death of Petya Evgenieva PETROVA-CIZEK

41y · Female·ligature compression of the neck (hanging)

Petya, a 41-year-old Bulgarian-born woman, died by ligature compression of the neck while an involuntary psychiatric patient at Bentley Health Service Ward 6 on 16 December 2020. She had been admitted following acute psy…

psychiatrydiagnosticcommunicationescitalopram

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