Coronial

346 results for mental health distress

NSWmental health2022-09-16

Inquest into the death of S B

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

…ndence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firearm at his wife in October 2016. He was transferre…

psychiatrygeriatric medicinediagnosticcommunicationolanzapine
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

…r-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-immolate due to distress about power cuts at his caravan park causing…

emergency medicinepsychiatrycommunicationsystem
WAprison2024-06-12

Inquest into the Death of Alf Deon EADES

46y · Male·head injury complicated by bronchopneumonia, with palliation

…ritical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress calls unprofessionally, failed to investigate requests for crisis care, and crucially, did not report a 3…

correctional healthneurosurgerycommunicationsystem
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

A 19-year-old male with depression and anxiety died by hanging at his home on 5 March 2021, hours after police and ambulance attended him in the early morning of 4 March following his brother's emergency call. Jet had co…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
WAcommunity2017-01-05

Inquest into the Death of Radinka MIHAJLOVIC

47y · Female·Multiple injuries from being struck by a train; death determined to be suicide

…ic care was inadequate, with serious miscommunications between Swan Valley Centre and Inner City Community Mental Health Service about whether depot olanzapine would be provided; (2) there was no coordinated multidiscipl…

psychiatrygeneral practicecommunicationsystemolanzapine
WAhospital2019-05-24

Inquest into the Death of Melanie Reanna TREGONNING

31y · Female·incised wounds to the neck and arms

A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…

emergency medicinepsychiatrycommunicationdiagnosticvenlafaxine
WAmental health2015-11-18

Inquest into the Death of Anna Maria CAMERON

65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…

Anna Maria Cameron, a 65-year-old woman with treatment-resistant schizophrenia, died from aspiration choking while eating on a psychiatric ward. She had been recently transferred to a rehabilitation unit for reassessment…

psychiatryintensive carelorazepam
VIChome2020-08-11

Finding into death of Angel Louise Hensgen

13y · Female·Acute paracetamol toxicity

…ity following intentional self-harm with an excessive overdose. She was exposed to intense cyberbullying, distressed by family relationships, peer conflicts, and a relationship breakdown, all while experiencing poor scho…

general practicetoxicologycommunicationsystemparacetamol
TAShome2022-11-29

Coroner's Finding: Young, Andrew Robert

61y · Male·hanging

…espite appearing positive and future-focused at a counselling appointment on 7 January, he became acutely distressed following a café meeting on 13 January where he expressed emotional pain regarding his back condition a…

psychiatrygeneral practicediazepam
WA2000-04-07

Inquest into the Death of Kenneth John Groth

47y · Male·Ligature compression of the neck (hanging)

…nces, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, causing significant distress. The coroner found he died by suicide. While finding no systemic failures in medical treatment or prison …

psychiatrycorrectional healthdiagnosticfluoxetine
SA2000-06-16

Coroner's Finding: CURREN Michael Andrew

38y · Male·neck compression due to hanging

Michael Andrew Curren, a 38-year-old prisoner at Mobilong Prison, died by hanging on 10 June 1998. He had been assaulted five days earlier and attended medical review on the day of death, but presented as being in good s…

communicationsystemparacetamol
VICcommunity2014-12-17

Finding into death of Paul Kanis

38y · Male·Organizing pneumonia with loculated pleural effusion in the setting of drug use …

…ical failure was lack of communication between his two treating doctors: Dr R. (ORT prescriber) and Dr H. (mental health provider). When Dr R. switched Paul from Suboxone to methadone on 11 January 2012, he did not infor…

general practiceaddiction medicinecommunicationsystemmethadone
WA- 12 September 2014

Inquest into the Death of Peter Philip HUMES

38y · Male·Ligature compression of the neck (hanging)

Peter Philip Humes, a 38-year-old Aboriginal man, died by suicide by hanging in Hakea Prison while on remand. He was assessed by prison officer Trevena and nurse Lee on admission using the MR011 'At-Risk' checklist and d…

general practicecorrectional healthsystemdelaymirtazapine
VIChome2021-01-20

Finding into death of Mitchell James Dowling

20y · Male·Hanging

…mation about relapse signs and proactive family engagement might have improved outcomes had he experienced mental health deterioration.

psychologypsychiatrycommunicationsystemalcohol
VIChome2025-05-21

Finding into death of Phillip Henry Reidy

27y · Male·Cyanide toxicity

Phillip Reidy, 27, died from cyanide toxicity after ingesting sodium cyanide during police arrest for a family violence incident. He had purchased 250g of sodium cyanide online from Bacto Laboratories using false informa…

forensic medicineemergency medicinecommunicationsystemsodium cyanide
WAhome2005-07

Inquest into the Death of taylor

29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath

…Louis was attempting to rebuild his life through education at Edith Cowan University. He was in emotional distress, struggling with systemic distrust, financial difficulties, and family issues. Two weeks before death, he…

psychiatrygeneral practicecannabis
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

…by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental health staff lacked access to Statement of Material Facts and PSOLIS database containing crucial psychiatr…

psychiatrypsychologydiagnosticsystemmethamphetamine
QLDhome2026-02-11

Inquest into the death of FSGT

50y · Male·Gunshot wound to the head

… police responded to a domestic disturbance. He had received appropriate, evidence-based multidisciplinary mental health treatment through ADF services. Two critical contributors were identified: alcohol intoxication (BA…

general practicepsychologysystemcommunicationamitriptyline
VIChome2020-06-05

Finding into death of Gregory Allen Floyd

43y · Male·Gunshot wound to the head

…clinicians did not adequately verify his serious allegations against her or assess family violence risk. A mental health assessment post-mortem indicated possible delusional disorder. The coroner identified that clinicia…

general practicepsychologydiagnosticsystemcodeine
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

…ust be reassessed in custody despite recent low-risk assessments in hospital; (2) integrated assessment of mental health and substance use is essential—his separate treatment as siloed issues in hospital and prison contr…

psychiatryemergency medicinediagnosticcommunicationalcohol
114151618

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