Coronial

746 results for psychiatric treatment

QLD2021-09-02

Batalha, Benjamin John

35y · Male·Not determined

Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…

psychiatrycorrectional healthsystemdiazepam
SAhospital2016-08-25

Coroner's Finding: ISSACSON David Jacob

52y · Male·disseminated carcinoma of the gallbladder

…vanced cancer with metastases was diagnosed on 8 April; he died the following day. The coroner found his treatment was appropriate and made no recommendations. Clinical lessons include the importance of thorough assessm…

general practiceemergency medicinediagnostic
VIChospital2013-09-10

Finding into death of Paul Gary Larman

28y · Male·Overdose of Clozapine

…priately prescribed clozapine without contacting the patient's mental health service despite knowing of psychiatric history and psychotic presentation; no communication between ED and mental health service regarding the…

psychiatryemergency medicinediagnosticmedicationclozapine
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

…ossible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St Vincent's Hospital Mental Health Service (SVHM) in the week before …

psychiatryemergency medicinecommunicationsystemsertraline
VIChome2024

Finding into death of B E

50y · Male·Neck compression and hanging

…ith PTSD, depression, and past polysubstance use, died by suicide via hanging. He had been engaged with psychiatric care since 2021, showing improvement with EMDR therapy and medication (escitalopram, medicinal cannabis…

psychiatrygeneral practicecommunicationdelayescitalopram
NSW2020-10-23

Inquest into the death of Ye Chiu

67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…

… died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hyponatraemia, and two previous psychiatric admissions. Whilst i…

psychiatryemergency medicinesystemcommunicationparoxetine
WAaged care- 11 April 2014

Inquest into the Death of Bill PORTELLI

64y · Male·bronchopneumonia in a man receiving palliative care for terminal cancer of the r…

…e at Alma Street Centre. He was an involuntary Mental Health Act patient. The coroner found supervision, treatment and care were exemplary. The deceased refused cancer diagnosis, believing his symptoms were caused by hi…

psychiatrypalliative carefentanyl
SAmental health2011-08-26

Coroner's Finding: REX Michael David

41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)

Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) w…

psychiatrypharmacysystemdelaymethadone
SAhospital2020-11-03

Coroner's Finding: ALLEN Wendy Elizabeth

75y · Female·general inanition and pneumonia on a background of end-stage dementia

…eimer's) died from general inanition and pneumonia. She was detained under a Mental Health Act Inpatient Treatment Order due to severe aggression and behavioural disturbance related to her dementia. She deteriorated pro…

psychiatrygeriatric medicinehydromorphone
SAhospital2020-06-25

Coroner's Finding: KARTINYERI Laura Rose

44y · Female·multi-organ failure and polypharmaceutical overdose on a background of severe ch…

… overdose on a background of severe COPD. She had a long history of substance abuse, non-compliance with treatment, and hospital presentations with refusal of care. In the months before death, her COPD was worsening des…

respiratory medicineintensive carepregabalin
VIChospital2025-07-08

Finding into death of KD

48y · Female·Combined effects of cardiac hypertrophy, chronic obstructive pulmonary disease a…

…OPD, cardiac hypertrophy and obesity, died from combined natural causes while under assessment order in psychiatric care. She presented with acute psychosis on 22 September 2022 and was placed under Mental Health Act as…

psychiatryintensive careolanzapine
VICcommunity2014-08-13

Finding into death of Frederick Russell Morgan

48y · Male·Unknown causes (presumed suicide by drowning)

…closed suicidal preoccupation for ten days—he was not admitted to hospital or given immediate intensive psychiatric care. Dr R. believed the danger had passed after their consultation, but Mr Morgan's condition deterior…

psychiatrypsychologydiagnosticdelayantidepressant medication
NT2014-11-03

Inquest into the death of Haidar Ali Ikhtiyar

62y · Male·Self-inflicted intentional hanging

…e inquired about suicide methods weeks earlier—information that was not relayed to treating clinicians. Psychiatric and psychological care was provided to an appropriate standard by qualified staff. The coroner found no…

psychiatrypsychologycommunicationsystem
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

…hizophrenia with command hallucinations. DJ died in 2012 from injuries inflicted by cellmate BB, who was treatment-resistant, non-compliant with medication, and acutely psychotic. Both deaths were preventable through be…

psychiatrydiagnosticcommunicationquetiapine
ACTcommunity2026-05-26

Inquest into the death of Donald Morley

93y · Male·Complications of invasive squamous cell carcinoma of the scalp

…. While in custody at North Canberra Hospital and subsequently at the hospice, Donald refused all active treatment including biopsy, preferring comfort-focused care aligned with his expressed wish to die. Multiple speci…

palliative carepsychiatry
NSW2018-08-31

Inquest into the death of MC

31y · Male·hanging

…d Centre while in lawful custody. He had been transferred to the Mental Health Screening Unit for acute psychiatric care after expressing paranoid ideation at Cessnock Correctional Centre. Critical clinical failures wer…

psychiatrycorrectional healthcommunicationsystemolanzapine
VIChome2017-04-19

Finding into death of Lauren Pilkington

20y · Female·Asphyxia secondary to inhalation of helium

…. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission at Delmont Private Hospital on 8 August 2016 after treatment for major depressive episode and…

psychiatrygeneral practicesystemdelayfluoxetine
VIChospital2013-09-17

Finding into death of Richard Hilton

27y · Male·Hanging

…roner found that staff focused narrowly on alprazolam withdrawal rather than recognising his underlying psychiatric illness. Optimal dual-diagnosis management requires coordinated treatment of both conditions; instead, …

psychiatryemergency medicinediagnosticcommunicationalprazolam
NSWcommunity2022-08-04

Inquest into the death of Brian Liston

51y · Male·Stab wound to the heart

…cted by William Cahill during an unprovoked attack at a bus stop in December 2015. Cahill suffers severe treatment-resistant schizophrenia and was found not guilty by reason of mental illness. The inquest examined wheth…

psychiatrytoxicologyclozapine
VICcommunity2016-12-05

Finding into death of Miroslaw Dziczkowski

40y · Male·UNDETERMINED - natural causes (most probably natural disease; starvation could n…

Miroslaw Dziczkowski, a 40-year-old man with paranoid schizophrenia managed under a Community Treatment Order, disappeared in January 2013 after withdrawing $7300 and relocating to a caravan park without noti…

psychiatryforensic medicinesystemdelayzuclopenthixol decanoate
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