Coronial
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WAhome2007-12-03

Inquest into the Death of Tedeschi

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…

psychiatrypsychologycommunicationdelayfluoxetine
SAhome2007-11-09

Coroner's Finding: RANDALL Treenor Heather

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…

general practicepsychiatrycommunicationdelayquetiapine
QLD2007-05-16

Davis, Jodie Maree

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…

psychiatrypsychologysystemcommunication
QLD2007-03-01

McGeary, Corey Allan

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…

psychiatrypsychologycommunicationsystemolanzapine
SA2007-01-30

Coroner's Finding: CHALKLEN Stuart Murray

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…

cardiologyemergency medicinediagnosticsystem
QLD2007-01-19

Carroll, Leon Mark

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…

psychiatrypsychologydiagnosticsystemdiazepam
NTcommunity2006-10-23

Inquest into the death of Jodie Palipuaminni

27y · Female·Intracranial haemorrhage with associated blunt head, chest and abdominal trauma

A 27-year-old Aboriginal woman was killed by her violent partner while he was on parole with conditions explicitly prohibiting contact with her. Despite documented escalating domestic violence over 12 years (including bo…

correctional healthforensic medicinesystemcommunication
WA2006-03

Inquest into the Death of Leon John Donaldson

20y · Male·Ligature compression of the neck (hanging)

Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified…

psychiatrypsychologysystemcommunicationsodium valproate
NTcommunity2005-07-19

Inquest into the death of Carlene Coombe

43y · Female·stab wound to the chest; contributing factors were aspiration of stomach content…

A 43-year-old Aboriginal woman died from a stab wound to the chest in circumstances that remain unclear. She had a complex history of depression, alcohol dependence, and family crisis (children removed from her care). Sh…

forensic medicinegeneral practicealcohol
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

Damien George Garlett, an 18-year-old Aboriginal remand prisoner at Hakea Prison, died by ligature compression of the neck (hanging) on 4 April 2003. He had a history of self-harm, drug-induced psychosis, violent offence…

psychiatrypsychologydiagnosticcommunication
NThome2003-12-19

Inquest into the death of Sunjay Chandra

25y · Male·hanging (self-inflicted)

A 25-year-old 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 reques…

psychiatrypsychologycommunicationsystemclozapine
WAcommunity2002-07-19

Inquest into the Death of Elizabeth Ann Studd

33y · Female·Immersion (drowning) by suicide

Elizabeth Ann Studd, a 33-year-old woman with longstanding borderline personality disorder, died by drowning in the Swan River on 28 August 1999. She had a severely traumatic childhood characterised by emotional neglect,…

psychiatrygeneral practicealprazolam
SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic episode. Hours before, he had been seen by a trainee psychologist who failed to reco…

psychologypsychiatrydiagnosticcommunication
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…

psychiatrypsychologyproceduralsystem
WA

Inquest into the Death of Stanley John INMAN

19y · Male·complications of ligature compression of the neck

Stanley John Inman, 19-year-old Aboriginal male, died by suicide at St John of God Midland Hospital on 13 July 2020, two days after ligature compression of the neck at Acacia Prison. He was on low-level ARMS (at-risk man…

psychiatrypsychologycommunicationsystemmirtazapine

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