Coronial

366 results for psychiatric admission assessment

WAhome2026-05-27

Inquest into the Death of Martin Carl QUITERIO

59y · Male·Multiple injuries

…rth. He had been discharged five days earlier on a Community Treatment Order following a 45-day hospital admission. On the morning of his death, after receiving a phone call about an upcoming CTO review, he visited the …

psychiatrygeneral practicesystemcommunicationhaloperidol
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

23y · Male·Neck compression as a result of hanging

…dicated for months before arrest. Critical failures in his mental health care included: delayed initial psychiatric assessment (3 weeks), inadequate intake screening that failed to establish rapport or document symptoms…

psychiatrygeneral practicediagnosticcommunicationolanzapine
VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

…d from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020 after a 14-day admission for a previous suicide attempt, placed on a …

psychiatryemergency medicinecommunicationdelayrisperidone
VICcommunity2010-10-15

Finding into death of Jason David Jenkins

34y · Male·Long drop hanging resulting in complete decapitation

…hanging resulting in complete decapitation) on 17 June 2006, approximately 6 weeks after discharge from psychiatric admission on a Community Treatment Order. He had a 15-year history of chronic paranoid schizophrenia, c…

psychiatryaddiction medicinesystemcommunicationmarijuana
SAmental health2009-12-04

Coroner's Finding: BLUNDEN Peter Ross

54y · Male·hanging by ligature

…anging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his admission, particularly after learning of imminent extended detention via Guardianship Board application. Critical…

psychiatryemergency medicinecommunicationsystemoxazepam
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

…He collapsed on 27 April 2020 and could not be revived. The coroner found clinical care appropriate: no psychiatric error was made in discharging him on 19 April; he refused physical assessment while agitated at BMHU, m…

psychiatryemergency medicinecommunicationolanzapine
NSWhome2018-04-26

Inquest into the death of FW

79y · Male·external neck compression as a result of hanging

… a Victorian Community Treatment Order (CTO) requiring fortnightly antipsychotic injections and regular psychiatric review before transferring to NSW. Once in NSW, critical failures occurred: his CTO was not implemented…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChospital2015-08-28

Finding into death of Moufid Sawan

61y · Male·Complications of cutaneous burns

…and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite clinical concerns about his mental state, he was pro…

psychiatryemergency medicinecommunicationdiagnosticrisperidone
VICcommunity2012-11-30

Finding into death of Simon Kirwan

19y · Male·Ruptured aorta post motor vehicle incident

…actively suicidal and didn't meet involuntary detention criteria. Critical failings included: incomplete assessment of his history and severity; clinician reliance on his verbal assurances despite known capability to dis…

psychiatryemergency medicinediagnosticcommunicationdiazepam
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

… suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asphyxiation as a contemplated suicide method. Following he…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
VICmental health2016-05-13

Finding into death of Shaun Luke Beagley

33y · Male·Mixed drug toxicity

… mixed drug toxicity (heroin, methylamphetamine, benzodiazepines) while on overnight leave from E-PARCS psychiatric residential facility. He had been admitted following suicide attempts and was managing depression, alco…

psychiatryassessmentcommunicationheroin
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

…disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service on 16 February 1999 following a serious …

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

Two psychiatric inpatients (SH, 25-year-old female; AW, 24-year-old male) died by suicide by jumping from the Buranda c…

psychiatrydiagnosticcommunicationhaloperidol
VIC2023-09-14

Finding into death of Darren Ricky Culleton

31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…

…ng to light himself on fire), was assessed by psychiatry and deemed not to meet criteria for involuntary admission, then was arrested for outstanding theft matters. In police custody at Melbourne West, he tied underwear…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
SAhospital2014-11-28

Coroner's Finding: ANDERSON Joel Kenneth

50y · Male·hepatic encephalopathy secondary to liver cirrhosis with background of hepatitis…

…inage, PICC line insertion for medication delivery, antibiotic treatment for peritonitis, and endoscopic assessment revealing oesophageal varices, his condition rapidly deteriorated. He was deemed unsuitable for transpla…

gastroenterologyhepatologyspironolactone
SA2003-03-20

Coroner's Finding: VARCOE Alexander Wayne Keith

24y · Male·hanging

…es included: failure to properly interpret a suicide risk screening form identifying him as at-risk upon admission; inadequate investigation procedures that failed to determine time of death; extensive unaddressed hangi…

psychiatrygeneral practicesystemcommunication
NSWhospital2017-09-08

Inquest into the death of James BARTON

21y · Male·external neck compression due to hanging; intentional self-harm

James Barton, aged 21, died by suicide on 27 March 2013, three days after discharge from psychiatric care. He was appropriately assessed and admitted as a mentally disordered person on 3 March following a…

psychiatrytoxicologysystemcommunicationalprazolam
VIChome2025-10-16

Finding into death of Ms YPM

27y · Female·Hanging

… with acute risks; (5) risk formulation for patients with borderline personality traits requires nuanced assessment balancing autonomy, therapeutic risk-taking, and family involvement.

psychiatryemergency medicinecommunicationdelayagomelatine
WAcommunity2005-11-04

Inquest into the Death of Sheridan Troy Hilton

42y · Female·Ligature compression of the neck (hanging)

…rioration, she was admitted to Busselton District Hospital on 18 August 2003 and transferred to Bentley Psychiatric Hospital on 21 August. Although assessed as a voluntary patient with protective factors (family support…

general practicepsychiatrycommunicationsystemmirtazapine
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