Coronial

475 results for psychiatric admission

QLDmental health2006-02-03

Muckan, David Jones

49y · Male·Obstructive sleep apnoea, contributed to by the sedating effects of therapeutic …

David Muckan, a 49-year-old man with schizophrenia, was admitted to a psychiatric unit in April 1998 with suspected obstructive sleep apnoea (OSA). He was sedated with benzodiazepines (…

psychiatryrespiratory medicinemedicationmonitoringthioridazine
VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

…services including Child Protection, Youth Justice, and the Adolescent Forensic Health Service. Despite psychiatric assessments identifying depression, anger issues, and trauma, psychiatrists recommended involuntary adm…

psychiatrypsychologysystemdelay
NSW2021-07-15

Findings into the death of MH

22y · Male·Hanging

…lth hospital to police custody following an alleged assault of another patient. Within a month of prison admission, he died by hanging, having accessed razor blades and exploited an obvious hanging point. Clinical lesso…

psychiatrycorrectional healthdiagnosticsystemzuclopenthixol
VICmental health2015-12-07

Finding into death of Jeffrey John Hartwig

43y · Male·Pneumonia

…hizophrenia and opiate dependence, died from pneumonia following cardiorespiratory collapse on an acute psychiatric inpatient unit. He was on multiple psychoactive medications including methadone (commenced 3 days prior…

psychiatryintensive caremonitoringcommunicationmethadone
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

… long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to Ballarat Health Services (7-14 July 2016) where he was treated under a Temporary Treatment…

psychiatryemergency medicinecommunicationsystemdextroamphetamine
VICcommunity2010-10-15

Finding into death of Jason David Jenkins

34y · Male·Long drop hanging resulting in complete decapitation

…hanging resulting in complete decapitation) on 17 June 2006, approximately 6 weeks after discharge from psychiatric admission on a Community Treatment Order. He had a 15-year history of chronic paranoid schizophrenia, c…

psychiatryaddiction medicinesystemcommunicationmarijuana
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

…Expert review found that while the team provided conscientious care with adequate monitoring, a hospital admission would have been prudent given the persistent suicidal ideation, continuing symptoms despite treatment, a…

psychiatrygeneral practicediagnosticcommunicationsertraline
QLDhospital2025-12-04

Inquest into the death of Dylan James Bell

28y · Male·Hanging

…tation—including drug-induced psychosis, prior violence toward his girlfriend, and explicit requests for admission—he was discharged home with inadequate safety planning. Clinicians did not fully explore Dylan's drug us…

psychiatryemergency medicinediagnosticcommunicationLSD
TAShospital2020-06-30

Coroner's Finding: Shrimpton, Dallas Brooks

54y · Male·carbon monoxide asphyxia

… December 2017 with suicidal ideation while intoxicated. Although appropriately triaged and assessed by psychiatric staff, he waited several hours without cubicle availability before being discharged voluntarily with co…

psychiatryemergency medicinecommunicationsystemalcohol
WAmental health2022-02-25

Inquest into the Death of Jordan James WILLIAMS

20y · Male·head and neck injuries sustained when struck by train

…ble; nursing staff were unaware he had been found near railway tracks; and security guards (not trained psychiatric nurses) provided supervision due to staffing shortages. Staff shortages on the unit prevented allocatio…

psychiatryemergency medicinesupervisioncommunicationolanzapine
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

…disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service on 16 February 1999 following a serious …

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
VICmental health2014-12-11

Finding into death of Sarah Lavinia Simpson

34y · Female·Multiple injuries due to impact with a train

…ah Simpson, a 34-year-old woman with bipolar affective disorder, died by suicide after exiting a locked psychiatric unit. She was admitted involuntarily on 30 January 2012 after expressing suicidal ideation and was disc…

psychiatryemergency medicinecommunicationsystem
SAmental health2025-03-06

Coroner's Finding: Fowles, Wayne Lincoln

59y · Male·hanging

A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …

psychiatryemergency medicinelorazepam
VIChospital2014-11-26

Finding into death of Daniel Colin McKittrick

25y · Male·Multiple injuries sustained in a fall from a height

…o contact him or his family. At Royal Melbourne Hospital on 12 June, he was assessed, accepted voluntary admission, but left the Emergency Department while escorted for fresh air by a psychiatric nurse. Key lessons: men…

psychiatryemergency medicinecommunicationsystemolanzapine
SAhospital2020-06-25

Coroner's Finding: ASHTON Lorraine June

78y · Female·advanced dementia (end stage)

… She had Primary Progressive Aphasia diagnosed in 2014 following non-Hodgkin's lymphoma treatment. After admission to RGH on 23 August 2017 with escalating behavioural disturbances including agitation, aggression, and f…

psychiatrygeriatric medicineoxazepam
SAhospital2007-07-02

Coroner's Finding: VINER Robert John

58y · Male·Hypoxic encephalopathy secondary to cardiac arrest due to cardiomegaly

…ardiac pathology (cardiomegaly) appears to have been undetected pre-arrest; cardiovascular assessment on admission may have identified this risk.

psychiatryemergency medicineolanzapine
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…

psychiatryemergency medicinesystemcommunicationamitriptyline
VICmental health2010-09-16

Finding into death of Louise Litis

37y · Female·Hypoxic brain injury consequent upon hanging

…cumentation of clinical reasoning and team communication. An independent review found medication and pre-admission management appropriate, but highlighted systemic failures in risk assessment processes, family engagemen…

psychiatryintensive carediagnosticcommunicationsertraline
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

…ed: no formal suicide risk assessment form completed; no 'no suicide contract' obtained (unlike previous admission); no search of belongings for potential ligature materials; assignment to a room not optimally positione…

emergency medicinepsychiatrysystemdelaykalma
WAhospital2005-02-04

Inquest into the Death of Alexander Albert Steinbrenner

36y · Male·Multiple injuries sustained from intentional jump from cliff top

Alexander Albert Steinbrenner, a 36-year-old man with schizo-affective disorder, died from multiple injuries sustained when he jumped from an 11-metre cliff at the Roundhouse in Fremantle on 27 February 2004. He was an i…

psychiatryemergency medicineflupenthixol
115161724

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.