Coronial

367 results for general anxiety disorder

VIChospital2022-04-11

Finding into death of C J

22y · Male·Hanging

A 22-year-old man with depression, alcohol addiction, and recent significant losses (parents, sister, friend) presented to Frankston ED on 14 January 2018 with active suicidal ideation and a specific plan to hang himself…

emergency medicinepsychiatrycommunicationsystemdiazepam
NSW2011-12-19

Villawoodfindings redacted

Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)

…orating mental health; mental health protocols were not followed, his diagnosis was incorrect (Adjustment Disorder rather than Major Depressive Disorder), and requests for transfer were ignored. David Saunders (UK nation…

psychiatrygeneral medicinediagnosticcommunicationmirtazapine
VIChome2025-09-02

Finding into death of Mr IKL

29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…

A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…

general practicepsychiatrydiagnosticmedicationgabapentin
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
VIChome2022-12-05

Finding into death of Paul Kenneth Wright

45y · Male·stab injury to the chest

Paul Kenneth Wright, aged 45, died from a stab wound to the chest inflicted in self-defence by Beau Muscat on 16 September 2021. Paul had an extensive custodial history, acquired brain injury, and intellectual disability…

general practiceforensic medicinesystemcommunicationmethamphetamine
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medications including benzodiazepines, anti…

general practicepsychiatrymedicationcommunicationflunitrazepam
SAmental health2011-08-26

Coroner's Finding: XU Yan Yi

50y · Female·compression of the neck consistent with hanging

Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICcommunity2026-04-15

Finding into death of LX

31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)

A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …

addiction medicinepsychiatrymedicationsystemmethadone
QLDhome2015-07-27

Howman, Katie Lee

30y · Female·Fentanyl overdose caused by self-administration of intravenous Fentanyl

…ne and 340 doses of tramadol through 'doctor shopping'—behaviour undetected by her treating psychiatrist, general practitioner, or AHPRA supervisors. Critical failures included: AHPRA's failure to routinely screen for o…

psychiatrypsychologydiagnosticsystemfentanyl
NThome2007-11-13

Inquest into the death of Richard Kiel

37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)

Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…

general practiceaddiction medicinediagnosticmedicationmethadone
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

…y mental health services. He died by suicide approximately 6 hours after discharge. The coroner found the general care was reasonable but identified significant deficiencies in discharge planning: PARC step-down admissi…

psychiatryemergency medicinesystemdelaymirtazapine
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
NSW2025-09-15

Inquest into the death of Robert Sievers

81y · Male·COVID-19 infection on a background of Type 2 Diabetes and end stage chronic kidn…

Robert Sievers, an 81-year-old man incarcerated since 2001, died from COVID-19 infection on a background of type 2 diabetes and end-stage chronic kidney disease. Despite multiple warnings about vaccination, Sievers refus…

geriatric medicinepalliative careantiviral medication
SA2015-06-24

Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…

psychiatrygeneral practicediagnosticsystemoxazepam
VIChome2022-12-01

Finding into death of Alicia Maree Little

41y · Female·Multiple injuries

Alicia Maree Little, aged 41, was struck and killed by a motor vehicle driven by her former intimate partner while she was leaving the relationship. The case highlights significant systemic failures in family violence re…

psychologypsychiatrydiagnosticcommunication
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three …

psychiatryemergency medicinediagnosticcommunicationalcohol
WAhome2016-02-10

Inquest into the Death of Adrian Marcus WESTLUND

22y · Male·Combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan and op…

Adrian Westlund, a 22-year-old with complex drug-seeking behaviour and polypharmacy addiction, died of combined drug toxicity (alprazolam, methadone, diazepam, dextromethorphan). He manipulated multiple GPs by misreprese…

general practiceaddiction medicinediagnosticcommunicationalprazolam
NSW2022-10-12

Inquest into the death of ZH

29y · Male·Hanging

ZH, a 29-year-old man serving a 9-year sentence for drug supply, died by hanging in his minimum-security cell at Parklea Correctional Centre on 11 August 2021. The coroner found his death was self-inflicted. Key clinical…

psychiatrygeneral practicecommunicationsystemmethamphetamine
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

…ing repeated suicidal ideation and threats during admission, she was assessed as 'low risk' and placed on general observation rather than high dependency care. She absconded on 22 June but returned cooperatively. On 24 …

psychiatryemergency medicinecommunicationsystemquetiapine
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine

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