Coronial

390 results for mental health deterioration

VICmental health2010-09-08

Finding into death of Brian O'Connor

73y · Male·Acute on chronic subdural haematoma due to recent head trauma in the context of …

Brian O'Connor, a 73-year-old man with vascular dementia, was admitted to a mental health inpatient unit following aggressive behaviour. He was placed on 15-minute observations due to Level…

psychiatryneurosurgerydiagnosticsystemfluphenazine
SAhospital2006-09-25

Coroner's Finding: McLEOD Peter Malcholm

28y · Male·Acute Dopamine Imbalance Syndrome

…ion with failure to recognise evolving neuroleptic malignant syndrome; delayed recognition of clinical deterioration.

psychiatryneurologycommunicationdiagnosticrisperidone
VIChome2021-08-12

Finding into death of M J

37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…

…ty Corrections management of both offenders' orders. MWJ failed to engage with mandated drug treatment and mental health services despite strong recommendations from ASCO for GP referral for mental health care plan. EW s…

general practicepsychiatrysystemcommunicationmethamphetamine
SAcommunity2023-10-13

Coroner's Finding: Adams, Michael Gerard

62y · Male·cardiac arrest complicating psychotic episode

…observation while restraining (no clinician maintained head-of-stretcher position), failure to apply supplemental oxygen despite visible cyanosis, and lack of awareness that psychiatric patients and antipsychotic medicat…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIChome2024-01-11

Finding into death of Madeline Jane Howe

20y · Female·Complications of neck compression in the setting of partial suspension

…olence, and her brother's death by suicide eight months prior. She was under care of North East and Border Mental Health Service (NEBMHS) with documented suicidal ideation, previous attempts via overdose and other means,…

psychiatryemergency medicinecommunicationsystemfluoxetine
WAhospital2005-03

Inquest into the Death of Bert Sharpe

58y · Male·Gastrointestinal haemorrhage due to erosive gastritis

…ury sustained in a motor vehicle accident in 1970. This injury caused chronic brain damage and progressive mental health deterioration requiring lifelong institutional care. In April 2004, he was admitted to hospital wit…

psychiatrygeneral surgery
NSWhome2015-10-09

Inquest into the deaths of Geoffrey Francis Hunt, Kim Jeanine Hunt, Fletcher Austin Hunt, Mia Isobel Hunt, Phoebe Amelia

Male·Gunshot wound to the head

…epression and emotional dependency; and family business financial disputes. The coroner found the medical, mental health, and disability support care provided to Kim was of high standard and that there were no signs clin…

psychiatrypsychologycitalopram
NSWcommunity2020-11-16

Inquest into the death of D B

39y · Male·Self-inflicted death by hanging

…method ideation and psychiatric history was unknown to responding officers. The coroner found insufficient mental health training, lack of access to medical records, and inadequate risk assessment contributed to the fail…

psychiatryemergency medicinecommunicationsystem
WAcommunity2022-08-18

Inquest into the Suspected Death of Nicholas PAVLIDIS

Male·Unknown - presumed deceased from exposure, heat exhaustion, or injury during unp…

… likely during an unplanned bush walk without adequate preparation or supplies. Pavlidis had deteriorating mental health, including increasing paranoia and social withdrawal, was not eating or sleeping well, and had aban…

general practicepsychologysystemdelayfluoxetine
VICcommunity2014-02-07

Finding into death of Bayden Joel Quilkey

30y · Male·unascertained

…nd showing signs of paranoid schizophrenia with self-inflicted lacerations. His brother Adam contacted the Mental Health Service twice seeking help. The triage service failed to mobilise a home assessment team, instead r…

psychiatryemergency medicinesystemcommunication
VIChospital2011-07-06

Finding into death of Tzu Lin Yang

59y · Female·multi-organ failure as a result of metastatic cervical cancer

… being deemed appropriate for palliative management. The coroner found her treatment was within reasonable healthcare parameters.

oncologypsychiatryolanzapine
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

…ctors. Annie's cancer treatment was interrupted due to financial conflict. Early intervention by family or healthcare providers regarding gambling harm, financial abuse recognition, and mental health support for Chai mig…

oncologygeneral practicesystem
VIChome2014-03-06

Finding into death of Melanie Jane Maher

36y · Female·Effects of fire (schizophrenic psychotic episode); for children: effects of fire…

…an 18-year history of schizophrenia requiring five involuntary psychiatric admissions, was discharged from mental health services in September 2007 to primary care without confirmed engagement with a GP. Toxicology showe…

psychiatrygeneral practicecommunicationsystemrisperidone
NSW2025-03-06

Inquest into the death of Leah Jane Porter

50y · Female·hanging

…e borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two psychiatrist reviews. Non-comp…

psychiatrygeneral practicecommunicationsystemmethylphenidate
WAmental health2015-11-30

Inquest into the Death of Frances May COOPER

48y · Female·Head injury

…ied from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Regional Hospital. She was an involuntary patient under the Mental Health Act 19…

psychiatryemergency medicineproceduralsystemrisperidone
VIC2022-02-01

Finding into death of Travis Thomas Young

42y · Male·hanging

…distress died by suicide while incarcerated. In the months preceding his death, he presented repeatedly to health staff reporting difficulty coping with tinnitus symptoms and requesting specialist referral. Days before d…

psychiatrygeneral practicesystemdelaymethadone
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

…. He had recently been distressed about a reported pregnancy with a girlfriend and experienced a rapid deterioration following his girlfriend ending their relationship. His presentation to Monash on 9 November 2010 with…

psychiatrygeneral practicediagnosticcommunicationtemazepam
VIChome2022-08-11

Finding into death of Christopher David French Hunter

31y · Male·hanging

…ted psychosis. Although parents contacted CATS twice (12 and 17 June), seeking guidance and expressing deterioration concerns, the community mental health team assessed Christopher on 18 June as not meeting compulsory t…

psychiatrycommunicationsystemolanzapine
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

…ld with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known mental illness, conducting me…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Matthew Patrick James Maher

36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …

…uary 2011 in a house fire following stab wounds to two children. She was discharged from Darebin Community Mental Health Service in September 2007 to GP care but never engaged with a general practitioner thereafter. The …

psychiatrypaediatricscommunicationsystemrisperidone
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