Coronial

346 results for mental health distress

NSWhospital2025-12-19

Inquest into the death of JBO

27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…

…ogical trauma following violent assault carries serious physiological consequences requiring comprehensive mental health support; protection order enforcement must be coordinated to prevent re-traumatisation; recognition…

emergency medicinecardiologycommunicationsystemamiodarone
VICcommunity2019-02-25

Finding into death of DH

40y · Female·Clozapine toxicity in a woman with cardiomegaly

A 40-year-old woman with depression, anxiety, alcoholism and undiagnosed cardiomegaly died from clozapine toxicity after obtaining the drug from a co-resident at a Peer Recovery Community. She was not prescribed clozapin…

psychiatrygeneral practicesystemcommunicationclozapine
VIChome2021-12-06

Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hyp…

psychiatryemergency medicinesystemcommunication
VIC2009-05-13

Coroner's Finding: Paul Wayne Carter

33y · Male·Multiple injuries consequent upon being struck by a truck

Paul Wayne Carter, a 33-year-old Aboriginal man with intellectual disability and mental health history, died on 7 August 2006 after being struck by a truck on the Sturt Highway near Mildura. Vic…

alcohol
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

…ed from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtained pentobarbitone fr…

psychiatrypsychologysystemproceduralpentobarbitone
VIChome2010-07-21

Finding into death of MF

29y · Female·Multiple stab wounds to the neck

…ssons include: GPs must recognise family violence risk factors (pending separation, controlling behaviour, mental health issues, suicidal ideation) and proactively refer to specialist family violence services rather than…

general practiceforensic medicinecommunicationsystem
QLDhospital2015-03-13

Cuttler, Melina Maree

29y · Female·Multiple injuries due to fall from height

A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. …

emergency medicinepsychiatrydiagnosticcommunication
VIChospital2022-03-09

Finding into death of Daniel McQuilken

68y · Male·Lung cancer

…out his detention, Mr McQuilken received reasonable and appropriate monitoring and care from International Health and Medical Services, with appropriate escalation following cancer diagnosis and multiple referrals to all…

oncologyrespiratory medicinechemotherapy agents
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

…s were used. Forensicare subsequently implemented significant improvements including standardised physical health monitoring systems, mandatory use of observation charts during seclusion, clearer escalation pathways, and…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
SAcommunity2005-03-14

Coroner's Finding: KEN Kunmanara

19y · Male·neck compression due to hanging

Kunmanara Ward, aged 19 years, died on 22 May 2003 by hanging from playground equipment at Indulkana Community while intoxicated by petrol sniffing. He had been sniffing petrol since early adolescence and was angry and u…

petrol
VIChome2013-07-16

Finding into death of Melanie Anne Reynolds

30y · Female·Mixed drug toxicity (propranolol, duloxetine and codeine)

… safety monitoring and therapeutic engagement is challenging; transition points between private and public mental health services require rigorous planning and communication; CATT staff lacked specific BPD training despi…

psychiatryemergency medicinecommunicationsystempropranolol
VICcommunity2012-09-13

Finding into death of XY

54y · Male·carbon monoxide toxicity

A 54-year-old man with a history of depression and previous suicide attempts by carbon monoxide poisoning died from carbon monoxide toxicity following his arrest and questioning regarding historical child sexual assault …

psychiatryforensic medicinesystemcommunication
NSWmental health2015-07-14

Inquest into the death of DA

34y · Male·Neck compression due to hanging

…abuse, high alcohol intake, and a recent suicide attempt died by hanging six weeks after being admitted to mental health services. Critical clinical lessons: (1) dual diagnosis (addiction and mental health) was not adequ…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
VIChospital2019-06-26

Finding into death of Trajce Laboski

27y · Male·Injuries sustained in descent from height

A 27-year-old man with schizophrenia was brought to Northern Hospital ED by police under Mental Health Act section 351 after threatening suicide and injecting testosterone. The Emergency Department doct…

emergency medicinepsychiatrydiagnosticproceduraltestosterone
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

…ohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist mental health and paediatric services, he lacked continuity of care (30 case managers in 14 years). Missed opport…

psychiatrypaediatricssystemdelay
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

…hosocial stressors including relationship separation, legal proceedings, and unstable housing. He accessed mental health support through Mallee District Aboriginal Services (MDAS), which provided appropriate community-ba…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
VIChospital2011-08-16

Finding into death of Lisa Irene Sharp

34y · Female·Hanging with combined effects of ethanol and benzodiazepines

…der for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a court hearing scheduled for 14 December. Police attended her …

psychiatryemergency medicinediagnosticcommunicationdiazepam
NSWmental health2011-06-23

Djordevic final

32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …

…-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unaware of her mental illness. After delivery, she…

obstetricsgeneral practicecommunicationsystemclozapine
SAhospital2000-06-16

Coroner's Finding: WANGANEEN Fallon

26y · Male·neck compression due to hanging

…bstance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key clinical failures included: inadequate psychiatric documentation of previous rope-ma…

psychiatryemergency medicinediagnosticcommunicationparacetamol/codeine
SAhospital2020-11-02

Coroner's Finding: MAGGS Eric Arthur

85y · Male·ischaemic heart disease

…ndly deaf from birth and had dementia. Admitted with acute chest pain and difficulty breathing, he became distressed and was refusing oxygen therapy. A Level 1 Inpatient Treatment Order was authorised to facilitate treat…

emergency medicinecardiologycefalexin
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