332 results
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
25y · Female·injuries sustained in fall from height
A 25-year-old woman with depression died by jumping from the West Gate Bridge. In the two months before her death, she attended four general practitioners across two medical practices with depression and anxiety, was com…
19y · Male·Hanging (intentional suicide)
This is a coronial finding into the death of Duke Mataku Tera, a 19-year-old of Maori descent who died by hanging on 1 May 2007. Duke had a history of depression, substance abuse, anger management issues, and previous su…
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …
40y · Male·Self-inflicted gunshot wound to the head
Trent Speering, a 40-year-old NSW paramedic, shot and killed his mother Monica, then shot himself on 11 June 2008. The coroner found that Trent suffered untreated paranoid personality disorder and depression. Despite mul…
26y · Male·Gunshot injury to the head (self-inflicted)
Mark Bailey, a 26-year-old with obsessive compulsive disorder, anxiety, alcohol dependence, and a history of violence, died from a self-inflicted gunshot wound. He was under treatment by a psychiatrist and psychologist w…
42y · Male·incised wound to the neck
Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…
36y · Male·Hanging
Tony Stanford, a 36-year-old remand prisoner with depression and a history of suicide attempt, died by hanging in his cell at Arthur Gorrie Correctional Centre on 19 September 2006. He was on a risk management plan requi…
38y · Male·self-inflicted hanging
Paul James Guarini, a 38-year-old university student with a history of relationship difficulties, suicide attempts, and depression, died by hanging in Cowdy ward at Royal Darwin Hospital on 14 September 2007, within 10 m…
Female·Drowning (suicide)
Melissa Maree Blake died by suicide by drowning on 16 January 2007 while receiving community-based treatment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental He…
54y · Male·Died by hanging while suffering from the effects of Post-traumatic Stress Disord…
A 54-year-old NSW police officer died by suicide while suffering from PTSD and Bipolar Disorder. He had witnessed multiple traumatic incidents during his 25-year career and was diagnosed with Bipolar Disorder in 2003. Fr…
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
14y · Female·Ligature compression of the neck (suicide)
Gabrielle Mia Tedeschi, a 14-year-old girl with longstanding oppositional and self-harm behaviours and subsequent depression, died by suicide on 14 October 2004 following a ligature compression injury sustained on 11 Oct…
50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)
Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…
24y · Female·hypoxic brain damage due to cardiac arrest due to hanging
Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, including multiple suicide attempts, and was assessed as high suicide ris…
20y · Male·Self-inflicted hanging
Corey McGeary, a 20-year-old remand prisoner with chronic risk factors for self-harm (history of suicide attempts, schizophrenia, personality disorder, severe childhood abuse, mild intellectual disability), died by hangi…
38y · Male·ischaemic heart disease due to severe coronary atherosclerosis
Stuart Murray Chalklen, aged 38, died in Adelaide Remand Centre from ischaemic heart disease due to severe coronary atherosclerosis. He complained of left shoulder pain (a recognised symptom of cardiac disease) to cellma…
Male·Self-inflicted hanging
Leon Mark Carroll died by hanging in prison while on remand for sexual offences. Initial assessment identified significant suicide risk, but this was reversed by the High Risk Assessment Team after only 5-6 minutes consi…
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