Coronial

366 results for psychiatric admission assessment

NSW2025-03-06

Inquest into the death of Moses Kellie

33y · Male·hanging

…tions. Detention officers showed genuine concern but lacked formal processes to escalate risk after his psychiatric admission. The coroner found the hospital treatment reasonable and discharge appropriate, but identifie…

psychiatrygeneral practicesystemcommunicationpaliperidone
VICmental health2015-02-02

Finding into death of CB

27y · Female·hanging

…borderline personality disorder and adjustment disorder died by hanging while voluntarily admitted to a psychiatric inpatient unit. She had presented with acute suicidality following relationship breakdown and job loss,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
NSWmental health2025-03-31

Inquest into the Death of G.P.

41y · Male·Multiple traumatic injuries

…e death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical lessons include: Dr J.'s…

psychiatryemergency medicinediagnosticcommunicationlisdexamfetamine
VICcommunity2020-05-11

Finding into death of Jolanta Boyd

48y · Female·Multiple injuries sustained when struck by a train

…5 May 2018 that injured her leg. At discharge from Alfred Hospital on 15 June 2018, she had appropriate psychiatric assessment and referrals arranged. The coroner found that medical services provided were reasonable and…

psychiatryemergency medicinecommunicationsystemalcohol
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehy…

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
QLDhospital2008-12-15

Van Putten, Patricia

49y · Female·Respiratory failure sequential to ingestion of Glyphosate due to depression and …

…d teacher, died by suicide via glyphosate ingestion on 18 February 2006, four days after discharge from psychiatric hospitalization for a serious self-harm attempt (throat laceration). She had complex comorbid Major Dep…

psychiatrygeneral practicecommunicationsystemdosulepin
TAS2021-03-19

Coroner's Finding: Hyatt, Saxon George

55y · Male·exsanguination resulting from self-inflicted wounds to left brachial artery and …

…, bipolar disorder, and depression, with poor medication compliance and heavy alcohol use. Prison health assessments were conducted appropriately on admission. After an assault by another inmate, Hyatt declined medical a…

psychiatrycorrectional healthduloxetine
VICcommunity2022-07-13

Finding into death of Dane Warren Simpson

52y · Male·Hanging

…t specialising in OCD, and a hospital crisis triage service. While he denied suicidal ideation on formal assessment in May 2019, he expressed increasing suicidal thoughts during a June crisis call but declined admission.…

general practicepsychiatrycommunicationfluoxetine
WAmental health2005-09-23

Inquest into the Death of Robert David Abbott

67y · Male·Ligature Compression of the Neck (Hanging)

…ory of depression exacerbated by chronic pain from a 2000 motor vehicle accident, and required multiple psychiatric admissions. On 18 December 2003, he disclosed to nursing staff that he had attempted to prepare a noose…

psychiatrygeneral medicineproceduralsystemvenlafaxine
WAmental health- 11 April 2014

Inquest into the Death of Aaron Luke PRISGROVE

32y · Male·ligature compression of the neck (hanging)

…th depression, alcohol abuse, and acromegaly, died by hanging on 12 July 2011, shortly after involuntary admission to Graylands Hospital's Smith Ward. He had presented to Tom Price Hospital on 8 July following a panadei…

psychiatryemergency medicinecommunicationsystemparacetamol/codeine
VICmental health2020-03-13

Finding into death of PATIENT A

35y · Female·mixed drug toxicity (fentanyl, morphine, clozapine and aripiprazole)

A 35-year-old woman with schizoaffective disorder, opiate use disorder, and amphetamine use disorder died from mixed drug toxicity (fentanyl, morphine, clozapine, and aripiprazole) after absconding from an inpatient ment…

psychiatryfentanyl
NSWhospital2018-04-27

Inquest into the death of Matthew Wilson Leary

25y · Male·drowning

Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and…

psychiatryemergency medicinediagnosticcommunicationcitalopram
NSWhome2016-09-30

Inquest into the death of Terry Riordan

45y · Male·multi-drug toxicity from ingestion of methadone and amitriptyline

…drug toxicity caused by ingesting amitriptyline and methadone in April 2015. He had complex medical and psychiatric comorbidities, substance abuse issues, and was under care of his GP Dr H. for 17 years. Critical clinic…

general practicepsychiatrymedicationdiagnosticmethadone
VIChome2014

Finding into death of Kathy Louise Tranter

48y · Female·head injuries from multiple blunt force trauma including punching, elbowing and …

A 48-year-old woman, Kathy Tranter, was killed by her 20-year-old son who was an involuntary psychiatric patient at Orygen Youth Health (OYH) with acute paranoid schizophrenia. The son was granted overnight l…

psychiatryemergency medicinediagnosticcommunicationrisperidone
VICpsychiatric inpatient unit2020-01-31

Finding into death of Damon Brenden Amiet

25y · Male·Injuries sustained when struck by a train (suicide)

…fective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serious suicide attempt by hanging. He died the next…

psychiatryemergency medicinecommunicationsystemolanzapine
QLDmental health2007-05-25

Mental Health patient

Female·multiple injuries due to a fall from height (suicide by jumping from multi-store…

…nd psychotic features died by suicide at a shopping centre car park on 21 September 2004, six days after admission to Belmont Private Hospital under an involuntary treatment order. She had attempted suicide in July 2004…

psychiatryemergency medicinecommunicationsystemmirtazapine
QLDhospital2015-07-28

Mills, Stephen John

57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…

…owong Private Hospital. Critical failures in falls risk management were identified: no formal falls risk assessment was completed on admission despite prior fall history, despite clear clinical indicators of increased fa…

psychiatryneurosurgerysystemcommunicationseroquel xr
NTmental health2002-03-12

Inquest into the death of Luke Peter Littlewood

21y · Male·multiple injuries from fall from water tower

A 21-year-old man with acute psychosis was admitted involuntarily to a psychiatric ward after being found climbing a power pole. After 8 days, despite being assessed at moderate suicide …

psychiatrycommunicationproceduralolanzapine
SAmental health2012-12-13

Coroner's Finding: Jenkinson Jacqueline Mary

46y · Female·mixed drug toxicity

46-year-old woman with bipolar disorder and chronic suicidal ideation died from mixed drug toxicity involving clozapine (prescribed to her roommate), olanzapine, fluoxetine, oxycodone, and diazepam. She disclosed to her …

psychiatrypsychologycommunicationsystemclozapine
NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

A 25-year-old university student with a complex history of schizoaffective disorder and substance misuse died by hanging during family leave from a mental health ward. He had been stable on depot antipsychotic medication…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
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