Coronial

346 results for mental health distress

VIC2017-03-30

Finding into death of Antonio Loguancio

40y · Male·Gunshot wound to the head, self-inflicted

…nsational media coverage describing him as 'Mad Dog'. The coroner found this media exposure significantly distressed Tony and likely contributed to his refusal to surrender. During the siege, police struggled to control …

communicationsystemmethamphetamine
SAhospitalPodcast2025-07-31

Coroner's Finding: Panella, Anna Vincenza and Skeffington, Bernard Anthony and Jessett, Graham Henry

Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…

…etter facilities, addressing triage workload, and cultural acceptance that ramping is inevitable in modern healthcare systems.

emergency medicinecardiologycommunicationsystem
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

… carer, and raped by a cousin before hanging. All three girls lacked coordinated support across education, health, child protection and police. Systemic failures include: failure to escalate child protection concerns des…

paediatricspsychiatrydiagnosticcommunicationalcohol
VICaged care2019-02-04

Finding into death of Margaret Elizabeth Barton

83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…

Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…

general practicegeriatric medicinemedicationcommunicationoxazepam
NSW2021-03-11

Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

…rt evidence confirmed that earlier ambulance dispatch could have given him a chance of survival. More fundamentally, during his four months in custody, Nathan's severe asthma was never properly assessed or managed; he wa…

respiratory medicineemergency medicinediagnosticsystemsalbutamol
NTmental health2019-09-13

Inquest into the death of Daniel Alexander Bleaney

37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof

Daniel Bleaney, 37, experienced acute psychosis with command hallucinations while at sea and attempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, foll…

psychiatryemergency medicinesystemdiagnosticdiazepam

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