Coronial

332 results for social isolation

VIChome2023-10-02

Finding into death of Student FSB

35y · Male·Multiple injuries sustained in a fall from a height

A 35-year-old international student from Taiwan died by suicide via fall from an 18-storey apartment building. He had prior diagnoses of anxiety disorder, psychotic disorder, and adjustment disorder documented in Taiwan …

psychiatrysystemcommunicationsertraline
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
WAcommunity2024-10-22

Inquest into the Death of Karl Jonathan TURNER

49y · Male·combined drug toxicity

Karl Turner, a 49-year-old man with schizoaffective disorder and chronic polysubstance use, died from combined drug toxicity (heroin, morphine, pregabalin, methylamphetamine, and cannabis). He was managed on a Community …

psychiatryintensive caresystemdelaymorphine
VIChome2025

Finding into death of Ms HRZ

48y · Female·Neck compression secondary to hanging

…base entry before full investigation, lack of specialist sexual assault crisis support referral, and her isolation despite brief contact attempts by family violence services. While the immediate cause was her decision t…

general practicepsychologysystemcommunication
WAmental health2014-06-11

Inquest into the Death of Lynn Desmond Ernest CHURCH

64y · Male·plastic bag asphyxia

A 64-year-old man with long-standing depression, personality disorder, and chronic pain died by plastic bag asphyxiation in a psychiatric hospital open ward. He had been admitted involuntarily after expressing suicidal i…

psychiatryemergency medicinecommunicationtramadol
ACThome2019-06-20

AN INQUEST INTO THE DEATH OFMARK ANTHONY O’BRIEN

58y · Male·Heroin toxicity

58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone)…

psychiatrypain medicinesystemcommunicationheroin
VIChome2022-11-25

Finding into death of Mr AS

30y · Male·Cyanide poisoning

A 30-year-old teacher in regional Victoria died from cyanide poisoning in June 2020. He presented to his GP in February 2020 with atypical features including fear of being poisoned, which raised concerns for possible psy…

general practicepsychiatrydiagnosticcommunicationpotassium cyanide
NThome2021-11-25

Inquest into the death of Sammy

9y · Female·suicide by hanging

A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and placed with non-Aboriginal carers despite legislation requiring Aboriginal …

paediatricspsychiatrysystemdelaymethylphenidate
SAcommunity2005-03-14

Coroner's Finding: Cooper Kunmanara

Male·Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposure in cont…

…until March 2004 deaths prompted urgent action. The coroner emphasised this was preventable through better social support, coordination, and service delivery.

psychiatrygeneral practicedelaycommunicationpetrol
VIChome2023-04-13

Finding into death of Martin William Sheahan

57y · Male·Gunshot wounds to the head and abdomen

Martin Sheahan, 57, was fatally shot by Glenn Usher-Clarke at his home on 26 January 2022. Usher-Clarke, who held a NSW firearms licence and permit to acquire, legally purchased a shotgun in Victoria on 17 December 2021 …

general practicepsychiatrycommunicationsystemmirtazapine
WA2018-03-08

Inquest into the Death of Moses SOKIRI

31y · Male·bronchopneumonia and hypoxic brain injury following ligature compression of the …

31-year-old Moses Sokiri died on 26 October 2014 from bronchopneumonia and hypoxic brain injury following suicide by hanging at Greenwood train station on 12 October 2014. The deceased was in acute mental health crisis w…

psychiatryemergency medicinecommunicationsystemvenlafaxine
NTcommunity1999-11-24

Inquest into the death of Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto

Unknown·Four deaths: three by self-inflicted hanging, one by multiple injuries from fall

…nd 199 mg/100ml). The coroner found no medical errors or clinical negligence; deaths resulted from complex social, cultural, and substance abuse factors affecting a remote Aboriginal community. Key preventive measures re…

alcohol
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

…on; prescription protocols must involve comprehensive addiction assessment; and multidisciplinary biopsychosocial pain management is critical to prevent despair.

neurosurgerypsychiatrycommunicationsystemfentanyl
QLD2025-10-15

Inquest into the passing of ATJ

43y · Male·Hanging

A 43-year-old First Nations man died by hanging while remanded in custody for domestic violence offences. Initial risk assessments on admission were adequate—a psychologist appropriately assessed him as not requiring enh…

psychiatrypsychologycommunicationsystemamitriptyline
VIChome2023-07-27

Finding into death of Loris Lesley O'Meara

75y · Female·Renal failure and ketoacidosis in a woman with chronic alcoholism and type 2 dia…

A 75-year-old woman with type 2 diabetes and chronic alcoholism died from renal failure and ketoacidosis at home. She was isolated, dependent on her elderly husband for care, and living in squalor. Over 20 disclosures of…

general practicegeriatric medicinecommunicationsystemmetformin
VIChome2015-07-15

Finding into death of Margaret Helen McCall

60y · Female·hanging

Margaret McCall, a 60-year-old woman with chronic regional pain syndrome and longstanding anxiety and depression, died by hanging. She received multiple ketamine infusions for pain management, with cessation of fentanyl …

pain medicinepsychiatrycommunicationsystemketamine
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

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

…ember 2017 despite ongoing psychotic symptoms. Relationship breakdown, stressors about his children, and isolation as a withdrawn inmate went unaddressed. Absence of Aboriginal Mental Health Workers contributed to failu…

psychiatrygeneral practicediagnosticcommunicationolanzapine
SAhome2025-03-07

Coroner's Finding: Bombardieri, Mark

32y · Male·Gunshot wound to the head

Mark Bombardieri, a 32-year-old man with a complex history of criminal behaviour, mental health disorders, polysubstance abuse, and multiple psychiatric admissions, died by suicide on 6 March 2019 via self-inflicted guns…

communicationmethamphetamine
VIChospital2019-03-01

Finding into death of Madeleine Therese Sobb

25y · Female·Airway obstruction complicating laryngeal dilation for the treatment of subglott…

Ms Sobb, a 25-year-old woman with spondylo-epi-metaphyseal dysplasia causing severe airway abnormalities and subglottic stenosis, died from airway obstruction following laryngeal dilation. She was admitted to ICU with as…

intensive careemergency medicinecommunicationsystemadrenaline
TAShome2021-12-03

Coroner's Finding: Summers, Damian

42y · Male·hanging, an action taken by himself with the intention of ending his life

A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural island where his partner and children had left. He had poor insight into his mental illn…

psychiatrygeneral practicecommunicationsystemolanzapine

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