Coronial
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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
NSW2015-12-18

Inquest into the death of Officer A

43y · Female·External neck compression due to self-inflicted hanging

A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…

psychiatrypsychologydiagnosticsystemprescription medication
VIChome2015-11-30

Finding into death of Anitha Mathew, Philip , Mathew George

37, 9, 5y · Female, male, male·Effects of fire

Three deaths (mother and two young sons) resulting from a fire deliberately set by the mother. A 37-year-old educated woman from India living in Australia experienced escalating isolation, marital conflict, and lack of e…

general practicepsychiatrysystemcommunicationzolpidem
VIC2015-10-30

Finding into death of Darcey Iris

4y · Female·Injuries sustained in fall from height

Darcey Iris Freeman, aged 4, was fatally injured when her father threw her from the West Gate Bridge on 29 January 2009 during a parenting dispute. Her mother had disclosed to GPs fears that the father could harm the chi…

general practicepaediatricscommunication
VIChospital2015-10-19

Finding into death of Daniella Francesca Sessarego

24y · Female·Pentobarbitone toxicity

24-year-old Daniella Sessarego died from pentobarbitone toxicity following intentional ingestion. She had borderline personality disorder and depression with a history of self-harm and suicidality. On 12 August 2014, she…

psychiatrypsychologysystempentobarbitone
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

Five family members were killed by gunshot on the evening of 8 September 2014 at Watch Hill farm, NSW. Geoffrey Hunt shot his wife Kim and their three children (Fletcher aged 10, Mia aged 8, and Phoebe aged 6) before tak…

psychiatrypsychologycitalopram
QLD2015-08-14

O'Connor, Scott Matthew

31y · Male·Hanging

Scott Matthew O'Connor, a 31-year-old male, died by suicide in the Maximum Security Unit of Arthur Gorrie Correctional Centre on 22 January 2013. He had been assessed as high-risk for self-harm and placed on 30-minute ob…

psychiatrypsychologydiagnosticproceduraltramadol
QLDhome2015-07-27

Howman, Katie Lee

30y · Female·Fentanyl overdose caused by self-administration of intravenous Fentanyl

Katie Howman, a 30-year-old registered nurse in the Critical Care Ward at Toowoomba Base Hospital, died from an intravenous Fentanyl overdose on 21 December 2013. Autopsy findings of crystalline granulomas in the lungs i…

psychiatrypsychologydiagnosticsystemfentanyl
VIChome2015-07-15

Finding into death of Margaret Helen McCall

60y · Female·hanging

Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …

pain medicinepsychiatrycommunicationsystemketamine
NSW2015-07-15

Inquest into the death of SW

42y · Male·Hanging

A 42-year-old male prisoner with a history of alcohol dependence, PTSD, and epilepsy died by intentional hanging in Cessnock Correctional Centre. Mental health assessments on reception and during detention found no suici…

psychiatrypsychologythiamine
QLD2015-05-28

Vetters, Farrin John

26y · Male·Neck compression from hanging

A 26-year-old man died by hanging in his correctional centre cell on 26 October 2011. He had a history of mixed personality disorder, anxiety, opiate dependence and previous suicide attempt (age 13), but was not assessed…

psychiatrycorrectional healthsystemcommunicationfluvoxamine
VICcommunity2015-04-09

Finding into death of Tomislav Brekalo

29y · Male·Injuries sustained in a fall from a height

A 29-year-old man with chronic paranoid schizophrenia died from injuries sustained after jumping from the EJ Whitten Bridge. He had a 5-year history of psychiatric illness with recurrent psychotic episodes despite treatm…

psychiatrygeneral practicecommunicationsystemolanzapine
VIC2015-01-30

Finding into death of Matthew Aaron Condie

21y · Male·upper airway obstruction and plastic bag asphyxia

Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable du…

psychiatrypsychologycommunicationsystem
NSWcommunity2015-01-30

Inquest into the death of Alec Samuel MEIKLE

17y · Male·Hanging (self-inflicted)

Alec Meikle was a 17-year-old apprentice in New South Wales who experienced bullying and harassment at his workplace at Downer EDI from January to May 2008. The incidents included creation of a 'Sphincter Dilation Chart'…

psychiatrygeneral practicesystemfluoxetine
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine
VICcommunity2014-12-22

Finding into death of Dean Alan Carlson Laycock

24y · Male·Strangulation by hanging

Dean Laycock, a 24-year-old man with intellectual disability and psychosis, died by hanging on Christmas Eve 2009, four hours after being informed that his anticipated 4-day Christmas leave from PARC (a psychiatric step-…

psychiatrypsychologycommunicationsystemclozapine
NSWhospital2014-12-19

Inquest into the death of JX

32y · Male·multiple injuries sustained in a fall from height

A 32-year-old man with a history of psychotic episodes and depression died by suicide after jumping from a cliff while experiencing an acute psychotic relapse. The case reveals critical failings in mental health crisis r…

psychiatrypsychologycommunicationsystemvenlafaxine
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…

Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…

psychiatrypsychologycommunicationsystemzolpidem
VIChome2014-11-28

Finding into death of Stephanie Jean Winberg

18y · Female·Compression of the neck in circumstances of hanging

Stephanie Winberg, an 18-year-old female with a complex medical history including eating disorder, major depressive disorder, and post-traumatic stress disorder following a friend's death, died by hanging on 16 October 2…

psychiatrypsychologyfluoxetine
VIChospital2014-11-26

Finding into death of Daniel Colin McKittrick

25y · Male·Multiple injuries sustained in a fall from a height

Daniel McKittrick, a 25-year-old man with depression, anxiety and recent-onset psychosis, died by suicide on 12 June 2012 after jumping from an eight-storey carpark while Victoria Police negotiators were present. He pres…

psychiatryemergency medicinecommunicationsystemolanzapine
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