Coronial

475 results for psychiatric admission

VICmental health2018-05-17

Finding into death of Lucas Richard Towndrow

51y · Male·Injuries sustained in a train incident

Lucas Towndrow, a 51-year-old involuntary psychiatric patient at Latrobe Regional Hospital, died by suicide on a railway track on 13 December 2016 after bein…

psychiatrydiagnosticcommunication
TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

…ol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He had complex neurocognitive impairment (d…

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
VIChospital2016-08-22

Finding into death of Alison Rae Wolinski

36y · Female·Hanging

A 36-year-old woman with borderline personality disorder and alcohol use disorder died by hanging approximately one month after discharge from St Vincent's Hospital. She had been admitted involuntarily following threats …

psychiatryemergency medicinecommunicationsystemvenlafaxine
VIChospital2015-04-23

Finding into death of Craig Ronald McMillan

37y · Male·Unascertained (death in custody)

…icated to attending paramedics or police. When the patient became acutely agitated and refused voluntary admission, both CAT team and ambulance paramedics declined to transport him, resulting in police assuming transpor…

psychiatryemergency medicinecommunicationsystemrisperidone
VIChome2023-06-06

Finding into death of Michael Stephen Delaney

37y · Male·Plastic bag asphyxia

… between treating psychiatrists and inpatient mental health facilities when patients are assessed during admission, particularly regarding treatment recommendations; (2) clarify responsibility for referrals between serv…

psychiatrycommunicationsystemdiazepam
VIC2011-09-01

Finding into death of Elijah Michael Shelley

28y · Male·heroin toxicity

Elijah Shelley, a 28-year-old with borderline personality disorder, depression, anxiety, and polysubstance abuse, was admitted to Alfred Health following a suspected heroin overdose suicide attempt on 27 October 2008. Un…

psychiatryheroin
WAhome2021-05-10

Inquest into the Death of Andre Walter BOND

42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…

…m upper airway obstruction (choking) on food while dining at home. He had been recently discharged from psychiatric inpatient care on a Community Treatment Order with a stable medication regimen including quetiapine, so…

psychiatryemergency medicinequetiapine
VICmental health2013-06-18

Finding into death of Paul Allan Skinner

29y · Male·hanging

Paul Skinner, a 29-year-old with depression and recent suicide attempt, was admitted to a psychiatric inpatient unit on involuntary status. Despite being prescribed 15-minute observations by his treating p…

psychiatrycommunicationsystem
NTmental health2019-09-27

Inquest into the death of Linden Kunoth

24y · Male·self-inflicted hanging

Linden Alan Kunoth, a 24-year-old Aboriginal man, died by suicide while on escorted leave from psychiatric care. He had been admitted with first-episode schizophrenia, presenting with florid psychosis and comma…

psychiatrydiagnosticsystemaripiprazole
SAmental health2008-07-17

Coroner's Finding: TARNOWSKI Marek Tomasz

33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphi…

A 33-year-old man with chronic back pain, depression, morbid obesity and sleep apnoea died in psychiatric custody from respiratory failure due to mixed drug toxicity and probable aspiration. He was heavily med…

psychiatryemergency medicinesystemamitriptyline
VIC2011-10-20

Finding into death of Jeremy Edward Chandler

49y · Male·Acute blood loss from a single incised injury to left forearm

…andler, a 49-year-old first-time prisoner, died by suicide in Melbourne Assessment Prison 36 hours after admission. He had been convicted of serious charges and remanded in custody pending sentencing. Despite meeting mu…

psychiatrycorrectional healthdiagnosticcommunication
VICcommunity2012-08-17

Finding into death of Jesse Ross Sangster

28y · Male·Multiple injuries sustained in a motor vehicle collision (driver)

…riday 29 January without case manager involvement or family notification; and failure to arrange urgent psychiatric review until 4 February, which never occurred. Post-discharge observations on 2 February showed clear r…

psychiatryparamedicinesystemdelayalcohol
VICmental health2020-03-17

Finding into death of Paul Peterson

54y · Male·Neck compression (hanging)

Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicid…

psychiatrysystemcommunicationcitalopram
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…

…on. The coroner found he should have been under continuous rather than close observations, and that key psychiatric warnings (paranoid comments, thought-disordered writings) were not adequately communicated to treating …

psychiatryemergency medicinediagnosticcommunicationescitalopram
VIChome2025-01-20

Finding into death of Kim Marie Bartolo

47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…

…on medications. She was admitted to Brunswick Private Hospital in October 2021 with a fractured hip and psychiatric review introduced a cross-titration medication regime (replacing venlafaxine with duloxetine, diazepam …

psychiatryorthopaedic surgerycommunicationmedicationvenlafaxine
VICcommunity2020-08-28

Finding into death of Heather Telfer

69y · Female·Toxicity to pentobarbitone in circumstances where she intended to end her own li…

…orating mental health were not formally escalated for specialist mental health review after her previous admission.

general practicerespiratory medicinecommunicationsystempentobarbitone
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

Jeremy Barker, a 27-year-old man with bipolar disorder, recent suicide attempts, and explicit stated intention to hang himself, was admitted to Arthur Gorrie Correctional Centre's medical unit for observation as an 'at-r…

psychiatrycorrectional healthcommunicationsystemcarbamazepine
VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

…th depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identified during initial as…

psychiatrygeneral practicesystemcommunicationmorphine
NSWmental health2015-07-14

Inquest into the death of DA

34y · Male·Neck compression due to hanging

A 34-year-old man with a history of polysubstance 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 dia…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
SAhospital2020-05-08

Coroner's Finding: HALL Bryan Robert

71y · Male·general inanition on a background of end-stage mixed pattern dementia and acute …

…ical history including Alzheimer's and vascular dementia, seizures, and chronic renal disease. His final admission followed behavioral deterioration and urinary tract infection. During hospitalization, he experienced mu…

geriatric medicinepsychiatry
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