Coronial

308 results for family crisis

NSWcommunity2015-01-23

Inquest into the death of XY

17y · Female·multiple blunt force injuries after being struck by a train

17-year-old X died by suicide on 18 December 2012 after being struck by a train. She received multiple psychiatric admissions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, an…

psychiatryemergency medicinefluoxetine
VIChome2018-07-10

Finding into death of Shrihan Gannaram

0y · Male·Multiple injuries sustained from impact with the ground from an extended height …

A 4-month-old boy fell from a third-floor balcony on 14 July 2015 in Melbourne, resulting in multiple injuries including abdominal stab wounds. His mother, despite experiencing postpartum depression and social isolation …

paediatricsobstetricssystem
NSWcommunity2021-08-18

Inquest into the death of A F

24y · Male·multiple stab wounds to the chest that he inflicted upon himself

…cation is discontinued, and close liaison between mental health services and primary care. Home visits and family engagement might have prevented relapse. The death was self-inflicted and not preventable by police, thoug…

psychiatrygeneral practicesystemcommunicationlurasidone
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

…e an Inpatient Assessment Order, critical gaps in GH's early assessments, continuity of care planning, and family engagement contributed to substandard care. Police response was appropriate. Lessons include need for mand…

psychiatryemergency medicinediagnosticcommunicationquetiapine
NSWhome2024-11-28

Inquest into the death of Michael Peachey

27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…

…custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On 20 May 2021, police attempted restraint outside his fathe…

emergency medicinepsychiatryproceduralcommunicationdroperidol
NSW2021-06-11

Inquest into the death of Lester Collins (a pseudonym)

51y · Male·Gunshot wound to the head

A 51-year-old man with a history of domestic violence died by suicide during a police vehicle stop. After breaching an AVO against his former partner, he violently assaulted her with a knife and then obtained a firearm f…

communicationsystem
QLDcommunity2009-06-19

Hatch, Clay

34y · Male·gunshot wound to the neck

…e officer's use of force was justified. While mental health treatment was appropriate and supported by his family, the incident highlights challenges managing severe psychosis with inadequate medication compliance, the d…

psychiatryemergency medicinecommunicationsystemamphetamine
NTcommunity1999-11-24

Inquest into the death of Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto

Unknown·Four deaths: three by self-inflicted hanging, one by multiple injuries from fall

Four Aboriginal Tiwi Islanders died in 1998 from suicide by hanging (three cases) and by falling from a power pole (one case). The inquest identified widespread alcohol and cannabis abuse, domestic violence, cultural dis…

alcohol
VICcommunity2024-11-11

Finding into death of Glykeria Skalistis

70y · Female·drowning (likely), but ultimately undetermined cause

…idepressant medications. For six months prior to her death she had ceased taking these medications, though family noted she appeared well. However, in the two weeks before her disappearance, subtle mood changes were note…

psychiatryemergency medicinediagnosticcommunicationantidepressants
VIChome2024-06-27

Finding into death of R B

44y · Female·Neck compression in the circumstances of hanging

…ion about risks of peer support groups during active proceedings; and improved information sharing between crisis services and victim support units. Death was in context of unresolved trauma, protracted legal processes, …

psychiatrypsychologycommunicationsystemvenlafaxine
VIC2022-03-08

Finding into death of Dylan James Charlton-Smith

25y · Male·Hypoxic ischaemic brain injury due to hanging

Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…

psychiatryemergency medicinediagnosticcommunication
NThome2026-03-20

Inquest into the death of Ralph Donald

35y · Male·self-inflicted gunshot wound to the head

Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…

psychiatryaddiction medicinesystemcommunication
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

…on-making capacity and discharged him. Key lessons: (1) Collateral history from treating psychiatrists and family is critical in capacity assessment, especially when patient presentation diverges from baseline; (2) Capac…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
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 failures in mental health ser…

psychiatryemergency medicinediagnosticcommunicationantidepressants
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

…n the week before admission. During hospitalisation, staff assessed him as improving and low risk, but his family warned that he was deliberately minimising symptoms to secure discharge. The treating psychiatrist (Dr T.,…

psychiatryemergency medicinecommunicationsystemvenlafaxine
QLDhome2022-07-12

Jack - Non-inquest findings

41y · Male·Stab wound to the chest

Jack, a 41-year-old man with extensive history of domestic violence perpetration across multiple relationships, died from a stab wound to the chest inflicted by his partner Sally during a domestic disturbance. Sally had …

forensic medicinecorrectional healthcommunicationsystemmethamphetamine
VICaged care2015-05-14

Finding into death of Philip John Roberts Hewitt

64y · Male·Acute traumatic subarachnoid haemorrhage secondary to single penetrating injury …

A 64-year-old man with schizophrenia was fatally stabbed in the eye by his roommate at a supported residential services facility. The roommate had a 12-year history of making specific threats to kill, including eye-pokin…

psychiatrygeneral practicediagnosticcommunicationolanzapine
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…

psychiatrygeneral practicesystemcommunicationalcohol
VIChome2022-05-03

Finding into death of Carol Austin

65y · Female·Plastic bag asphyxia

…th practitioners are scarce, and how restricted eligibility for telehealth services limits alternatives to crisis-focused tertiary care.

psychiatrygeneral practicesystemcitalopram
112131416

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