Coronial

746 results for psychiatric treatment

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
VICprison2014-01-24

Finding into death of Adam Sasha Omerovic

40y · Male·Ligature compression of the neck in circumstances of being hanged

… cell on 23 March 2010. He had been remanded on armed robbery charges and was classified as P1 (serious psychiatric condition requiring intensive care) and S2 (significant suicide risk) on admission. Despite this high-r…

psychiatrycorrectional healthdiagnosticsystemescitalopram
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality …

psychiatryemergency medicinesystemcommunicationmirtazapine
VICaged care2011

Finding into death of Mr CR

43y · Male·hypoxic brain injury secondary to asphyxiation by ligature

…mentation. Key lessons: suicidal ideation must be immediately reported to medical teams and documented; psychiatric reassurance alone does not justify reduced vigilance; best practice handover and recording procedures a…

neurosurgeryrehabilitation medicinecommunicationsystem
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

…. He died post-extubation from massive PE. Key clinical lessons: (1) The referring unit lacked adequate psychiatric infrastructure, seclusion facilities, and ECT capability for managing acutely aggressive patients; (2) …

psychiatryintensive caresystemdelayaripiprazole depot
VICcommunity2002-06-07

COUPER Gregory

43y · Male·Hypoxic/ischaemic encephalopathy resulting from asystolic cardiac arrest due to …

Gregory David Couper, 43, with chronic schizophrenia, experienced a psychiatric crisis at a supported residential care facility on 2 December 1998 and died the next day from restraint…

psychiatrypathologyproceduralcommunication
SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

…ained under the Mental Health Act due to concerns about oral intake and anticipated non-cooperation with treatment. Despite appropriate supportive care including nasogastric feeding and intravenous hydration, she develo…

neurologypsychiatry
QLD2026-04-24

Findings of the Inquest into the death of Benjamin Freear

40y · Male·Gunshot wound to neck

… amphetamine and benzodiazepines. Expert evidence confirmed appropriate ADHD diagnosis and mental health treatment by both psychiatrist and GP, with prescribing consistent with best practice. The Coroner made no recomme…

psychiatrygeneral practicesystemdextroamphetamine
VIChome2019

Finding into death of Rachel Naomi Mihail

36y · Female·Nicotine toxicity

Rachel Mihail, a 36-year-old with a complex psychiatric history including PTSD, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 No…

psychiatrygeneral practicecommunicationsystemnicotine
SAmental health2023-06-30

Coroner's Finding: Williamson, Vaughan Weston

41y · Male·undetermined

Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neurop…

psychiatryemergency medicineolanzapine
NSW2024-08-22

Inquest into the death of Russell Zaska

33y · Male·hanging

…and and Reception Centre on 23 September 2020. He had been remanded in custody for three weeks. Despite psychiatric assessment on 15 September identifying psychotic symptoms and thought disorder, he was commenced on ant…

psychiatrycorrectional healthsystemdelayolanzapine
VICmental health2012-10-12

Finding into death of Grant Elliot Phillips

29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)

Grant Phillips, 29-year-old with schizophrenia and complex psychiatric history including multiple suicide attempts, was admitted involuntarily to Broadmeadows Inpatient Psych…

psychiatrydiagnosticsystemdextroamphetamine
NThome2003-12-19

Inquest into the death of Sunjay Chandra

25y · Male·hanging (self-inflicted)

…d man with schizophrenia died by suicide while on a Community Management Order following discharge from psychiatric hospital. He had been effectively stabilized on clozapine for years, but in late 2001 requested dose re…

psychiatrypsychologycommunicationsystemclozapine
SAmental health2004-07-30

Coroner's Finding: CURNOW Robert Norman

81y · Male·myocardial infarction

…at Glenside Hospital. He was admitted for aggression and cognitive deterioration. Over three weeks, his psychiatric medication (olanzapine, carbamazepine) was adjusted as he appeared to improve. He collapsed suddenly on…

psychiatrygeneral practiceolanzapine
VICcommunity2019-04-16

Finding into death of Sophie Margery Nicholas

27y · Female·Injuries sustained in motor vehicle incident (pedestrian)

…ersonality disorder (BPD) and alcohol dependency, with frequent crises involving multiple admissions to psychiatric units and private rehabilitation facilities. Despite extensive engagement with mental health services, …

psychiatryaddiction medicinecommunicationsystemalcohol
VICmental health2015-07-08

Finding into death of David Allan D'Angelo

30y · Male·Heroin toxicity

… 30-year-old Aboriginal man with schizophrenia and polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic relapse. His symptoms improved rapidly with antipsych…

psychiatryemergency medicinesystemdelayheroin
VICcommunity2022-11-23

Finding into death of Carl Robert Adler

46y · Male·Cold environmental exposure in a man with cardiomegaly

Carl Robert Adler, a 46-year-old man with treatment-resistant schizophrenia, intellectual disability, and autism, died from cold environmental exposure comp…

psychiatrydiagnosticsystemclozapine
SAhospital2004-02-13

Coroner's Finding: WHITE Kevin Charles

57y · Male·aspiration pneumonia secondary to small bowel obstruction

…ervention was deemed futile given his unstable condition. The coroner found no criticism of his hospital treatment. Clinical lessons include: early recognition of aspiration risk in patients with dysphagia or altered me…

emergency medicinesurgeryquetiapine
VIC2015-11-05

Finding into death of Kasim Colic

79y · Male·Unascertained

… careful risk assessment before approving extended overseas leave for patients with complex medical and psychiatric conditions; clear communication and documentation of clinical status during overseas treatment; ensurin…

psychiatrygeriatric medicinecommunicationsystem
SAhospital2010-08-18

Coroner's Finding: STORRIE Victor James

38y · Male·terminal respiratory failure due to chronic obstructive lung disease on a backgr…

…ely transitioned to palliative care and died within days. The coroner found his detention was lawful and treatment appropriate throughout. This case illustrates the challenges of managing end-of-life care in patients wi…

intensive carerespiratory medicine
116171838

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