Coronial
NSWaged care2022-09-28

Inquest into the death of Kerry-Ellen (Nikki) Knight

44y · Female·Hanging

…ltiple clinical opportunities were missed: the initial mental health screening failed to identify her known PTSD, anxiety and depression despite these being documented in available electronic records; her self-referral f…

psychiatrycorrectional healthdiagnosticcommunication
VIC2019-02-25

Finding into death of Thomas Murphy

36y · Male·Acute myocardial infarction due to ischaemic heart disease with severe coronary …

… risk factors including a history of poly-drug use (methamphetamine and cannabis), depression, anxiety, and PTSD. The coroner found no suspicious circumstances and was satisfied that custodial and healthcare management m…

forensic medicineemergency medicinecitalopram
VIChome2024-05-14

Finding into death of PJQ PJQ

18y · Female·Multidrug toxicity (GHB, amphetamines, benzodiazepines)

…es) after being discharged early from a residential rehabilitation program. She had complex trauma history, PTSD, and polysubstance abuse. Following early discharge from the Gippsland Youth Residential Rehabilitation Pro…

paediatricspsychiatrysystemdelayGHB
TAShome2022-07-21

Coroner's Finding: Moran, Kayla Maree

31y · Female·hanging

A 31-year-old woman with a long history of depression, anxiety, and PTSD died by hanging. She experienced multiple concurrent stressors: workplace sexual harassment and threats, en…

general practicepsychiatrydiagnosticcommunication
VIChome2024-06-27

Finding into death of R B

44y · Female·Neck compression in the circumstances of hanging

…d by hanging following rape in 2014 and protracted criminal proceedings. She experienced ongoing trauma and PTSD exacerbated by reopening her complaint and multiple court processes. She had multiple suicide attempts over…

psychiatrypsychologycommunicationsystemvenlafaxine
TAShome2022-06-20

Coroner's Finding: Williams, Julie Gaye

59y · Female·mixed prescription drug and alcohol toxicity (ethanol, diazepam, fluoxetine, and…

…l toxicity with aspiration of gastric contents. She had extensive psychiatric history including depression, PTSD, bipolar disorder, and alcohol dependence, with multiple prior suicide attempts. On 9 June 2019, after cons…

psychiatrygeneral practicealcohol
VIC2021

Finding into death of Thi Minh Phuong Nguyen

29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…

…oxicity (GHB, methylamphetamine, amphetamine, diazepam). She had multiple mental health diagnoses including PTSD, depression, bipolar disorder, and postnatal depression. Her son was removed to foster care following a fam…

general practicepsychiatrycommunicationsystemgamma hydroxybutyrate
NSW2025-07-24

Inquest into the death of PF

45y · Male·Hanging

…ional or justice health services were identified, and the one-out cell placement was appropriate given PF's PTSD and prior assault trauma. No recommendations were made.

psychiatrypsychologydelay
NSW2015-07-15

Inquest into the death of SW

42y · Male·Hanging

A 42-year-old male prisoner with a history of alcohol dependence, PTSD, and epilepsy died by intentional hanging in Cessnock Correctional Centre. Mental health assessments on rec…

psychiatrypsychologythiamine
QLDmental health2024-09-17

Inquest into the death of Chloe Jane Campbell

32y · Female·Hypoxic-ischaemic encephalopathy due to hanging

…bell, aged 32, died by suicide while an involuntary inpatient with borderline personality disorder, complex PTSD, and chronic suicidal ideation. She was admitted 18-30 April 2019 after ceasing medications and experiencin…

psychiatryintensive caresystemlorazepam
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

…the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, developing PTSD from combat exposure including witnessing a close friend's death by IED. Post-discharge, Jesse faced signif…

psychiatryparamedicinesystemcommunicationduloxetine
VIChome2016-12-12

Finding into death of Drew Dax

46y · Male·Stab injury to the neck

…motional and physical abuse. Both men had untreated mental health conditions (depression, bipolar disorder, PTSD), substance use issues, and childhood trauma. Police had attended twice for family violence incidents in 20…

general practicepsychiatrydiazepam
VICcommunity2022-11-22

Finding into death of Vlado Tomislav Micetic

44y · Male·gunshot wound to the abdomen

…t with audio-visual evidence. Critical issues included Baker's unmonitored mental health (bipolar disorder, PTSD, depression), inadequate fitness-for-duty assessments by police medical officers, and the 3-year delay in i…

emergency medicinepsychiatrysystemdelaycarbamazepine
SA2019-12-20

Coroner's Finding: MORGAN Martina

60y · Female·neck compression by ligature strangulation

…sified as 'high need' rather than 'medium risk' based on her gross intoxication, reported suicidal history, PTSD diagnosis, and assertion of recent overdose. Mandatory 15-minute observations and CCTV monitoring were inad…

diagnosticcommunicationalcohol
WA2024-06-12

Inquest into the Death of Petra Michelle MARQUIS

40y · Female·ligature compression of the neck (hanging)

…rquis, a 40-year-old woman with a documented history of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being charged with drin…

psychiatryemergency medicineduloxetine
VIChome2021-12-17

Finding into death of B H

49y · Male·hanging

A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence int…

psychiatrypsychologycommunicationsystemantidepressant medication
VIChome2018-07-29

Finding into death of Diane Maria Hillgrove

34y · Female·Mixed drug toxicity

Diane Maria Hillgrove, a 34-year-old woman with chronic pain, PTSD, anxiety and substance abuse history, died from mixed drug toxicity on 7 July 2018. Post-mortem toxicology …

general practicepsychiatrysystempregabalin
QLD2015-10-09

(P) a thirteen year old girl

13y · Female·Multiple injuries due to motor vehicle accident

…ercation with youth workers and died in a high-speed motor vehicle crash. She had extensive trauma history, PTSD, reactive attachment disorder and ADHD. The coroner found the youth workers acted appropriately and no poli…

paediatricspsychiatrysystemdelay
VIChome2025-03-14

Finding into death of Jonathan Mark Townsend

59y · Male·Unascertained

Jonathan Townsend, a 59-year-old Navy veteran with PTSD, alcohol use disorder, and multiple psychiatric comorbidities, died at home on 5 November 2021. The cause o…

trauma surgerypsychiatrycommunicationsystemdiazepam
VIChome2025-01-31

Finding into death of FCP

45y · Female·Drowning whilst inebriated (ethanol)

…ome in Kilmore East, Victoria. She had a complex history of mental illness (psychosis, depression, anxiety, PTSD), substance abuse, and was in a relationship with controlling and abusive dynamics. Following a deteriorati…

psychiatryemergency medicinesystemcommunicationalcohol

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