Coronial

389 results for severe depression

NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

…ears before developing tardive dyskinesia. His treating psychiatrist ceased the medication to address this severe side effect, and he relapsed with paranoia and suicidal ideation four months later. He was readmitted to h…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
SAhospital2011-11-03

Coroner's Finding: BALLARD Margaret Dawn

76y · Female·aspiration of gastro-intestinal contents as a result of small bowel obstruction …

…eliance on potentially unreliable history from a dementia patient, insufficient diagnostic weight given to severe collapse, inadequate observation period, and failure to escalate deterioration at the receiving facility. …

emergency medicinepsychiatrydiagnosticcommunicationsodium valproate
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disord…

psychiatrygeneral practicecommunicationsystemolanzapine
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

…voluntary mental health admission (discharged 27 May 2007) for attempted suicide, chronic alcohol abuse, depression, and psychosis. Critically, physicians at Royal Perth Hospital did not access discharge summaries from t…

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
WAhome2016-07-21

Inquest into the Deaths of Jessica Rose CUZENS and Jane Lesley Margaret CUZENS and Heather GLENDINNING

46y · Female·Ms Glendinning: multiple sharp force injuries (suicide); Jane Lesley Margaret Cu…

Heather Glendinning, severely mentally ill with chronic paranoid delusions exacerbated by cannabis abuse and stress from family court …

psychiatrygeneral practicecommunicationsystemcannabis
TAShospital2021-02-05

Coroner's Finding: Lattimer, Joseph Aaron

37y · Male·hypoxic encephalopathy due to asphyxia from hanging

… or treatment before entering a toilet and attempting suicide by hanging. He was resuscitated but suffered severe hypoxic brain injury and died 11 days later. Critical failures included: no Psychiatric Emergency Nurse (P…

emergency medicinepsychiatrysystemdelayalcohol
SAhospital2006-08-22

Coroner's Finding: DENNIS Jessica-Lee

16y · Female·consequences of acute asthma with hypoxic encephalopathy

…osis and severity assessment; (3) asthma severity was underestimated—by 3 May, Jessica-Lee had moderate-to-severe asthma requiring hospitalisation and oral prednisolone, not just preventer therapy; (4) poor communication…

general practicerespiratory medicinediagnosticcommunicationsalbutamol
VIChospital2020-04-16

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

…as increased to 10mg three times daily without in-person review. She was found unresponsive on 27 May with severe hypoxia and died from hypoxic-ischaemic encephalopathy. Critical failures included: ambiguous communicatio…

pain medicineemergency medicinecommunicationdiagnosticmethadone
VICmental health2012-03-13

Finding into death of Matthew Spalding

28y · Male·neck compression subsequent upon hanging

Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …

psychiatryemergency medicinecommunicationsystemaripiprazole
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

… She was never medically screened despite being received during an unprecedented COVID-19 outbreak causing severe staff shortages. Throughout her custody, she reported nausea, vomiting, inability to eat or drink, and req…

general practicegastroenterologydiagnosticdelay
NSWhome2010-08-26

Coroner's Finding: Kate Therese Bugmy

26y · Female·Streptococcal Sepsis resulting from Skin Ulceration and complications of Cerebra…

…er's death in 2004, the family's capacity to manage her complex needs deteriorated. By June 2007, Kate was severely malnourished, dehydrated, and had extensive infected pressure sores. Her family delayed seeking medical …

general medicineemergency medicinesystemcommunication
NSWhome2018-04-26

Inquest into the death of FW

79y · Male·external neck compression as a result of hanging

A 79-year-old man with bipolar affective disorder and a documented history of medication non-compliance died by suicide while living in rural NSW. He had been subject to a Victorian Community Treatment Order (CTO) requir…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2024-02-05

Finding into death of Ms KSI

22y · Female·Complications of cutaneous burns

A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing f…

general practiceemergency medicinecommunicationsystem
NSWmental health2019-11-29

Inquest into the death of Harold EDWARDS (a pseudonym)

49y · Male·Hanging

A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospit…

psychiatrydiagnosticcommunicationtemazepam
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

… died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and emotional abuse from her partner Mr TT …

psychiatrypsychologycommunicationsystemalprazolam
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance…

psychiatrygeneral medicinecommunicationsystemolanzapine
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI o…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

…rway caused dynamic hyperinflation, leading to cardiac arrest. The autopsy revealed previously undiagnosed severe subglottic stenosis. Earlier recognition would have allowed joint surgical-anaesthetic planning or procedu…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
QLDhospital2016-09-02

Calder, Michael James

33y · Male·Opiate toxicity

A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both sl…

general medicineemergency medicinemedicationdiagnosticmorphine

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