Coronial

390 results for mental health deterioration

VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

…, responses to family violence disclosures could have been improved. Key clinical lessons include: private mental health professionals lack mandatory family violence training and are not prescribed under MARAM; mental he…

psychiatrypsychologycommunicationsystemalprazolam
NSW2017-08-31

Inquest into the death of David WOTHERSPOON

31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging

…year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferred to a specialised ment…

psychiatrycorrectional healthsystemcommunicationrisperidone
VICcommunity2018-03-14

Finding into death of C P

59y · Female·Gunshot injuries to the head

…motional family violence throughout their relationship. CP had experienced abuse since childhood, suffered mental and physical health complications, and became dependent on alcohol. She was receiving psychiatric support …

psychiatrydiagnosticcommunicationcitalopraam
SAhospital2005-04-05

Coroner's Finding: HOLLENS Christopher

44y · Male·aspiration pneumonia

…enside psychiatric hospital on 11 November 2002 with signs of chest infection and progressive physical deterioration. At RAH, he received appropriate diagnosis and treatment including antibiotics, seizure management, an…

psychiatrygeneral medicinephenytoin
VICmental health2013-02-25

Finding into death of Joy Apostolopoulos

41y · Female·Multiple injuries due to impact by train

Joy Apostolopoulos, a 41-year-old woman with schizophrenia and depression, died by suicide when struck by a train after absconding from a locked psychiatric ward at Alfred Hospital. She had been on escorted leave, became…

psychiatryemergency medicinecommunicationsystemclozapine
VIChome2023-05-25

Finding into death of Emma Gertrude Weidemann

76y · Female·Effects of fire in a woman with head and neck injuries

Mrs Emma Weidemann, aged 76, died from burns sustained in a fire deliberately set by her husband Rudolf at their home on 11 December 2019. Rudolf had recently been diagnosed with terminal cancer, experienced cognitive de…

oncologypsychiatrydiagnosticcommunicationvenlafaxine
VICcommunity2014-08-25

Finding into death of Travis Joseph Hartskeerl

32y · Male·Head and neck trauma (train impact)

…ide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from Peninsula Health community mental health services to GP care in April 2008 on antipsychotic depot injections, antidepressan…

psychiatrygeneral practicecommunicationsystemzuclopenthixol decanoate
QLDhospital2016-11-23

SPB - Non-inquest findings

36y · Male·hanging

A 36-year-old man with 15-year history of paranoid schizophrenia and polysubstance abuse presented to hospital after violent behaviour toward his father while intoxicated. Despite police concerns, family requests for adm…

psychiatryemergency medicinediagnosticcommunicationdiazepam
NSW2015-10-27

Inquest into the death of Kevin Norris

38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…

Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Community Treatment…

emergency medicineintensive caredelaycommunicationmethamphetamine
QLD2013-04-18

McCarty, Lawrence

45y · Male·exsanguination due to incised wound to neck

…sertraline, and medication was not formally flagged for monitoring despite his history; (3) no referral to mental health services occurred despite previous self-harm episode in records; (4) medication rounds were not man…

general practicepsychiatrydiagnosticcommunicationsertraline
VICmental health2012-03-06

Finding into death of Nikos Karagiannis

26y · Male·Unascertained on an unequivocal medical or pathological basis; likely multifacto…

…de sudden unexpected nocturnal death in epilepsy (SUNDE) or related mechanisms. Earlier recognition of deterioration or more frequent clinical observations might have enabled intervention, though the underlying pathophy…

psychiatryforensic medicinedelaysystemclozapine
VIChome2025

Finding into death of Ms HRZ

48y · Female·Neck compression secondary to hanging

…iew. This systems abuse—compounded by cultural shame fears within her Turkish community—precipitated rapid mental health deterioration despite psychological support. She feared community exposure of intimate recordings M…

general practicepsychologysystemcommunication
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

…November 2009. Despite his partner repeatedly requesting hospitalisation and expressing concerns about deterioration, the team decided to manage him in the community with medication adjustments and close monitoring. The…

psychiatrygeneral practicediagnosticcommunicationsertraline
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

…cident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long history of violent offending and mental health issues including chronic suicidality precipitated by relationship breakdown. Police were called aft…

general practiceemergency medicinesystemalcohol
VICcommunity2024-04-19

Finding into death of Michael Molony

68y · Male·Unknown; likely suicide by unknown means

…ichael Molony, a 68-year-old man living alone in Yarraville, disappeared on 3 January 2020 after reporting health concerns to family. He had a history of skin cancer treated in 2015-2017 but was not receiving ongoing med…

oncologypublic healthcommunication
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

…certainty, no family or local support, no consular assistance, and severe depression with anxiety. Top End Health Service provided minimal psychiatric care with brief consultations (3-31 minutes), insufficient history-ta…

general practicepsychiatrydiagnosticcommunicationsertraline
SAmental health2016-06-09

Coroner's Finding: FALLON Peter John William

40y · Male·Unascertained; likely cardiac arrhythmia secondary to cardiomegaly and morbid ob…

…e floor at 0600 hours did not cover him or place his head on a pillow, which may have identified acute deterioration. While this poor nursing care was not directly causative, it represented a failure in basic clinical o…

psychiatryintensive carecommunicationsystemrisperdal consta
TAShospital2017-08-22

Coroner's Finding: AH - de-identified

37y · Female·asphyxia due to hanging

…as not sent, preventing timely community follow-up within 48 hours that might have identified clinical deterioration the following day.

psychiatryemergency medicinediagnosticcommunicationescitalopram
SAhospital2022-08-15

Coroner's Finding: Larchin, John

87y · Male·infective exacerbation of chronic obstructive lung disease

An 87-year-old man with a long smoking history and no prior diagnosis of lung disease suffered a hip fracture requiring surgery. Postoperatively, he developed delirium and hypoxia. Two Inpatient Treatment Orders were app…

orthopaedic surgerypsychiatryhaloperidol
NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

…ild protection service had closed the case file prematurely in February 2015 despite known severe maternal mental illness and prior child removal; the community mental health team discharged the mother on 9 September des…

general practicepsychiatrycommunicationsystemtriflouperazine
115161720

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