Coronial

475 results for psychiatric admission

SAhospital2021-11-23

Coroner's Finding: Barry, Margaret Joan

80y · Female·Right haemothorax due to bleeding right pleural adhesion with contributing apixa…

…ixaban anticoagulation therapy for atrial fibrillation. She was admitted to Royal Adelaide Hospital for psychiatric care under an Inpatient Treatment Order for mania following cessation of carbamazepine. On 24 April 201…

psychiatrycardiologyapixaban
VICmental health2011-07-22

Finding into death of Lionel Raymond Perry

44y · Male·Cardiomegaly

… died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric inpatient. He presented with hypertension and withdrawal symptoms on admission; initial management incl…

psychiatryemergency medicinecommunicationdocumentationmethadone
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He wa…

psychiatryaddiction medicinemedicationproceduralmethadone
SA2003-03-20

Coroner's Finding: VARCOE Alexander Wayne Keith

24y · Male·hanging

…es included: failure to properly interpret a suicide risk screening form identifying him as at-risk upon admission; inadequate investigation procedures that failed to determine time of death; extensive unaddressed hangi…

psychiatrygeneral practicesystemcommunication
SAcommunity2009-12-16

Coroner's Finding: PENN Dulcie Janet Mary

83y · Female·Congestive cardiac failure due to ischaemic and valvular heart disease

…medication administration error in a community group home. On 1 July 2007, she received her housemate's psychiatric medications (including clozapine, risperidone, valproate, and lamotrigine) instead of her own cardiac m…

emergency medicineintensive caremedicationproceduralclozapine
VICcommunity2022-07-13

Finding into death of Dane Warren Simpson

52y · Male·Hanging

…assessment in May 2019, he expressed increasing suicidal thoughts during a June crisis call but declined admission. The coroner made no criticism of treating clinicians but recommended that professional colleges (RACGP,…

general practicepsychiatrycommunicationfluoxetine
VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

…d from exsanguination following self-inflicted incised wounds to both arms. He had been discharged from psychiatric inpatient care on 1 February 2020 after a 14-day admission for a previous suicide attempt, placed on a …

psychiatryemergency medicinecommunicationdelayrisperidone
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

23y · Male·Neck compression as a result of hanging

…dicated for months before arrest. Critical failures in his mental health care included: delayed initial psychiatric assessment (3 weeks), inadequate intake screening that failed to establish rapport or document symptoms…

psychiatrygeneral practicediagnosticcommunicationolanzapine
WAmental health2005-09-23

Inquest into the Death of Robert David Abbott

67y · Male·Ligature Compression of the Neck (Hanging)

…ory of depression exacerbated by chronic pain from a 2000 motor vehicle accident, and required multiple psychiatric admissions. On 18 December 2003, he disclosed to nursing staff that he had attempted to prepare a noose…

psychiatrygeneral medicineproceduralsystemvenlafaxine
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

… suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asphyxiation as a contemplated suicide method. Following he…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
VICmental health2015-02-02

Finding into death of CB

27y · Female·hanging

…borderline personality disorder and adjustment disorder died by hanging while voluntarily admitted to a psychiatric inpatient unit. She had presented with acute suicidality following relationship breakdown and job loss,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
VICcommunity2020-05-11

Finding into death of Jolanta Boyd

48y · Female·Multiple injuries sustained when struck by a train

…5 May 2018 that injured her leg. At discharge from Alfred Hospital on 15 June 2018, she had appropriate psychiatric assessment and referrals arranged. The coroner found that medical services provided were reasonable and…

psychiatryemergency medicinecommunicationsystemalcohol
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…

…ptly recognized as such. (3) Fractures from falls were not identified radiologically until late hospital admission, delaying pain management. (4) Poor handover between facilities prevented essential clinical information…

general practicegeriatric medicinemedicationcommunicationoxazepam
NSWhospital2018-04-27

Inquest into the death of Matthew Wilson Leary

25y · Male·drowning

Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and…

psychiatryemergency medicinediagnosticcommunicationcitalopram
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

…ural and mental health crises from adolescence. Despite multiple emergency department presentations and psychiatric admissions, he was repeatedly discharged with inadequate community follow-up. A critical gap existed in…

psychiatryemergency medicinediagnosticcommunicationcitalopram
NSWmental health2025-03-31

Inquest into the Death of G.P.

41y · Male·Multiple traumatic injuries

…e death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical lessons include: Dr J.'s…

psychiatryemergency medicinediagnosticcommunicationlisdexamfetamine
QLDhospital2008-12-15

Van Putten, Patricia

49y · Female·Respiratory failure sequential to ingestion of Glyphosate due to depression and …

…d teacher, died by suicide via glyphosate ingestion on 18 February 2006, four days after discharge from psychiatric hospitalization for a serious self-harm attempt (throat laceration). She had complex comorbid Major Dep…

psychiatrygeneral practicecommunicationsystemdosulepin
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

…He collapsed on 27 April 2020 and could not be revived. The coroner found clinical care appropriate: no psychiatric error was made in discharging him on 19 April; he refused physical assessment while agitated at BMHU, m…

psychiatryemergency medicinecommunicationolanzapine
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

…ng behavioural changes as potential warning signs, and assessing suicide risk in patients with comorbid psychiatric illness and substance misuse.

psychiatrygeneral practiceolanzapine
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehy…

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
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