Coronial

366 results for psychiatric admission assessment

QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

… clinical lessons: (1) suicide risk is dynamic and must be reassessed in custody despite recent low-risk assessments in hospital; (2) integrated assessment of mental health and substance use is essential—his separate tre…

psychiatryemergency medicinediagnosticcommunicationalcohol
VIChome2015-07-15

Finding into death of Margaret Helen McCall

60y · Female·hanging

…ultiple ketamine infusions for pain management, with cessation of fentanyl during her July 2012 hospital admission. Pain recurred within 5 weeks of the final infusion, a known limitation of ketamine's temporary effects.…

pain medicinepsychiatrycommunicationsystemketamine
NSWhospital2026-01-22

Inquest into the death of JC

30y · Male·hanging

JC was a 30-year-old with a long history of benzodiazepine dependence and previous psychiatric episodes triggered by withdrawal. He presented to Calvary Mater Hospital after a deliberate overdose of…

emergency medicinepsychiatrydiagnosticcommunicationetizolam
VICmental health2023-04-20

Finding into death of Craig Harvey

50y · Male·Hanging

…onality disorder, died by hanging in Casey Hospital's mental health inpatient ward while on a compulsory admission. He was a known high-suicide-risk patient under hourly observations. The coroner found his death was pre…

psychiatrysystemdelaydiazepam
VICcommunity2019-06-13

Finding into death of Diane Bell

52y · Female·Plastic bag asphyxia and asphyxia in the setting of an irrespirable environment

Diane Bell, a 53-year-old woman with delusional disorder and chronic suicidal ideation, died by argon gas inhalation in June 2017. She had been under care of North West Area Mental Health Service with a Community Treatme…

psychiatrypsychologyolanzapine
WAhospital2019-03-08

Inquest into the Death of Seanpol Martin Padraig O'NEILL

30y · Male·methadone toxicity

…ith schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodiazepines, and anti…

psychiatryemergency medicinecommunicationsystemmethadone
QLDmental health2013-07-02

Saccu, Jonathan Clarence

20y · Male·Multiple injuries due to contact with a train

Jonathan Saccu, a 20-year-old with severe treatment-resistant schizophrenia, absconded from an open mental health unit and was fatally struck by a train approximately 3 hours later. He was admitted on an involuntary trea…

psychiatrydiagnosticcommunicationdiazepam
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

… the mental health ward following his suicide attempt but did not complete a formal family violence risk assessment despite documented evidence of multiple high-risk factors including separation, substance abuse, access …

psychiatryemergency medicinediagnosticcommunicationsertraline
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

…9% of Kimberley students attend infrequently); and insufficient mental health infrastructure (no secure psychiatric facility in the Kimberley). Twenty-seven recommendations addressed governance, housing, education, alco…

public healthpsychiatrysystemdelayalcohol
SA2003-01-17

Coroner's Finding: ALLEN Craig Mark

29y · Male·Hanging

…k Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The Health …

correctional healthpsychiatrycommunicationsystemfluoxetine
VICmental health2024-04-26

Finding into death of Allison Leah Randall

37y · Female·Hanging

…oman with a history of anxiety, depression, and childhood trauma, was admitted to the Northern Hospital psychiatric unit on 15 May 2020 following acute concerns about her partner's behaviour towards their daughter. She …

psychiatrysystemdiazepam
ACThome2017-03-23

AN INQUEST INTO THE DEATH OF PAP

55y · Male·Septicaemia due to hydronephrosis and infection

…ticoagulation, alcohol dependence, depression, and chronic hoarding behaviour. Despite repeated hospital admissions and professional interventions, he refused all community support and home visits post-discharge. The co…

cardiologypsychiatrysystemcommunicationwarfarin
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired…

psychiatryneurologydiagnosticcommunicationolanzapine
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

…ebruary 2019 with severe suicidal ideation and a reported self-harm attempt. Despite appropriate initial assessment by the admitting psychiatrist (Dr B.) and placement on Level 2 observations (15-minute checks), key syst…

psychiatryemergency medicinecommunicationsystemaripiprazole
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

… October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital Mental Health Unit; discharged from Yarrabah hospita…

psychiatrygeneral practicediagnosticcommunicationflupenthixol
VICcommunity2016-09-06

Finding into death of Antonio D'Augello

63y · Male·Drowning

…etween treating teams despite both being aware of his involvement; no family consultation to inform risk assessment or discharge planning despite documented family concerns and his impaired judgement; no psychiatrist rev…

psychiatryemergency medicinecommunicationdelayolanzapine
VIChospital2019-06-26

Finding into death of Trajce Laboski

27y · Male·Injuries sustained in descent from height

… and injecting testosterone. The Emergency Department doctor (Dr K.) assessed him, determined he needed psychiatric admission, but did not make a formal assessment order under section 30, relying on a Northern Hospital …

emergency medicinepsychiatrydiagnosticproceduraltestosterone
VICcommunity2015-09-24

Finding into death of GC

42y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…il; he was assessed by a mental health nurse and psychiatrist who determined he did not meet involuntary admission criteria and released him pending community follow-up. Two days later, he engaged in erratic driving beh…

psychiatryemergency medicinesystemdelaycannabis
VIChome2010-04-27

Finding into death of David Mathew Smith

32y · Male·plastic bag asphyxia

David Mathew Smith, 32, died by plastic bag asphyxia on 25 November 2007. He had schizophrenia, chronic motor tic disorder, sexual paraphilia, and a history of explosive-making offences. He was subject to concurrent bail…

psychiatryforensic medicinemedicationcommunicationrisperidone
NSWcommunity2021-06-08

Inquest into the death of Zhong Liu

54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…

…ially with language barriers; (2) mental health deterioration with aggressive behaviour warrants urgent psychiatric assessment despite current calm presentation; (3) clinicians prescribing these drug combinations should…

psychiatrygeneral practicemedicationcommunicationdoxepin

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