Coronial

304 results for chronic suicide risk

NSWmental health2022-09-16

Inquest into the death of S B

81y · Male·cardiac arrest following neck compression due to hanging

An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…

psychiatrygeriatric medicinediagnosticcommunicationolanzapine
QLDcommunity2024-08-21

Inquest into the deaths of Charmaine, Aaleyn, Matilda, Wyatt, and Zaidok McLeod

Female·multiple injuries from motor vehicle collision (for all five deceased)

…; better communication between police, mental health, child protection and legal services may identify high-risk individuals; and legal practitioners should understand mental health crises and trauma-informed practice wh…

psychiatryemergency medicinesystemcommunicationfluvoxamine
VIChome2017-09-21

Finding into death of ALJW

21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia

…rated psychological support during transition from paediatric to adult care, and failure to identify high suicide risk were significant contributing factors. Key lessons: holistic assessment of mental health in chronic

cardiologypsychologycommunicationsystemheroin
VIChomeNew2026-06-09

Finding into death of A T

42y · Male·Gunshot injury to the head

…olence incident reported to Child Protection weeks prior did not trigger assessment of firearms access as a risk factor. The coroner recommended legislative amendments requiring firearms applicants to provide medical evi…

psychiatrysystemketamine
NThospital2026-02-10

Inquest into the death of Martin Leach

67y · Male·Congestive cardiac failure

…T Health ultimately obtained legal advice supporting respect for his APP. He was inappropriately placed 'At Risk' for health monitoring rather than genuine suicide/self-harm concerns. The finding highlights systemic gaps…

emergency medicinecardiologysystemcommunicationmorphine
TAScommunity2018-01-25

Coroner's Finding: Lockwood, Shane

45y · Male·Stab wound to the chest, self-inflicted

Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge …

psychiatrygeneral practicecommunicationsystemclozapine
SAmental health2016-11-17

Coroner's Finding: ALCOCK, Ross Matthew

22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…

A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observations, he hung himself using an electrical cord in his wardrobe. The ward layout ha…

psychiatryintensive caresystemcommunicationolanzapine
NSW2022-08-18

Inquest into the death of Gavin Ellis

31y · Male·hanging

…hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm history. Following his psychiatric ass…

psychiatrycorrectional healthdiagnosticcommunicationaripiprazole
NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease.…

neurologyneurosurgerycommunicationsystemmadopar
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

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

… a free fall. The investigation initially focused on foul play but the coroner concluded this was neither suicide with intent nor homicide. Critical clinical lessons include: psychologists treating acutely suicidal pati…

psychiatrypsychologycommunicationsystemzolpidem
WAhospital2010-02-04

Inquest into the Death of Hudson

20y · Male·Ligature compression of the neck (hanging)

…ices, unreliable medication charting, failure to escalate to involuntary status or transfer despite clear suicide risk, and lack of a secure environment. The coroner found deficiencies in observation chart design, medic…

psychiatryemergency medicinediagnosticcommunicationcarbamazepine
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

… major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days after remand. He had been recently discharged from hospital following suicidal ideation…

psychiatrycorrectional healthcommunicationsystemmirtazapine
WAhome2018-03-22

Inquest into the Death of Aileen Helen QUARTERMAINE

60y · Female·effects of fire in a woman with alcohol effect

A 60-year-old woman with chronic paranoid schizophrenia died in a domestic fire on 26 July 2014. The day before, her son sought help from …

psychiatryemergency medicinecommunicationdiagnosticpaliperidone
NSWcommunity2021-10-22

Inquest into the death of Terence Gray

54y · Male·Multiple injuries from collision with motor vehicle

Terence Gray, a 54-year-old man with chronic alcohol abuse and depression, was removed from a train at Grafton by a Passenger Services Supervisor (Mr …

psychiatryemergency medicinecommunicationsystemalcohol
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

…spital on 5 February 2020 expressing intent to jump in front of a train. Despite being assessed as moderate risk and deemed suitable for admission, he was discharged due to lack of available beds. He re-presented on 7 Fe…

psychiatryemergency medicinediagnosticcommunicationduloxetine
QLDmental health2026-01-29

Inquest into the death of Tiesha Marie Derbyshire

18y · Female·Mixed drug toxicity

…erdose attempts. Key clinical lessons: (1) propranolol and similar cardioactive medications pose particular risks in patients with eating disorders due to cardiovascular complications and high overdose lethality; (2) sta…

psychiatrygeneral practicecommunicationsystempropranolol
SA2005-03-14

Coroner's Finding: Ward Kunmanara

Unknown·Multiple causes including neck compression due to hanging (Ward, Ryan, Cooper) a…

This inquest into four deaths on the Anangu Pitjantjatjara Lands involved multiple causes including hanging (three cases) and exposure with complications. Kunmanara Ward died by hanging while intoxicated with petrol; Kun…

psychiatryemergency medicinecommunicationsystempetrol
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

…ures: inadequate Aboriginal liaison officer access, poor family engagement, understaffing, and inconsistent risk assessment practices. Key lessons: psychotic depression requires continuous supervision; observations must …

psychiatryemergency medicinediagnosticcommunicationescitalopram
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

Joel Cauchi, a 40-year-old man with chronic treatment-resistant schizophrenia, carried out a stabbing attack at Westfield Bondi Junction shopping cen…

psychiatrygeneral practicecommunicationsystemclozapine
VICcommunity2017-07-07

Finding into death of SO

27y · Male·Mixed drug toxicity

…provement in mood and engagement during substance use disorder treatment do not eliminate imminent overdose risk, particularly following discovery of active drug use. Enhanced discharge planning, closer follow-up interva…

psychiatryaddiction medicinedischargesystemheroin

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