Coronial

35 results for acute psychological crisis

WAcommunity2023-02-28

Inquest into the Death of Paul James BRADY

35y · Male·multiple injuries

…in critical incidents. The case highlights the need for adequate training in managing vulnerable people in crisis, including recognition of the fight/flight/freeze physiological response.

emergency medicineforensic medicineproceduraldelaytemazepam
VICcommunity2022-08-01

Finding into death of X Y

53y · Male·Multiple gunshot injuries

…d man with longstanding unresolved childhood trauma, affected by COVID-19 pandemic restrictions, developed acute paranoia and anxiety. Believed people were hacking his devices and tracking him. When school welfare staff…

psychiatryemergency medicinecommunicationsystem
SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic …

psychologypsychiatrydiagnosticcommunication
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

…nded the range the same day without safety screening. Raymond Jast, 54, experiencing marital and financial crisis, also accessed firearms readily despite an instructor noting concerning behaviour. The coroner identified …

psychiatryemergency medicinesystemcommunication
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

…May 2023 and was initially placed on ARMS (At-Risk Management System) with close monitoring. Following psychological reviews in June, he was removed from ARMS on 8 June 2023 despite his counsellor Rebecca Forster recomm…

psychiatrypsychologysystemcommunicationamitriptyline
VIChome2011-10-18

Finding into death of Lynette Ann Kent

52y · Female·Multiple stab injuries

…view highlights failures in: early identification and disclosure of family violence risk; victim access to crisis services; perpetrator mental health assessment; and coordination between primary care and domestic violenc…

general practiceemergency medicinecommunicationsystem
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

…ple mental health services. Critical clinical lessons include: (1) improved handover communication between crisis teams and day staff after high-risk calls is essential—Ms S disclosed a medication stockpile and suicidal …

psychiatrygeneral practicecommunicationsystemphentermine
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

…ccupation with reinstatement. Risk reduction strategies discussed (secure storage, not shooting alone, psychological treatment) were not adhered to. The coroner identified a systemic gap: no clinical guidelines or struc…

psychiatrygeneral practicediagnosticsystemmethylphenidate
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

…ally placed on the Disturbed and Vulnerable list with recommendations for mental health monitoring and psychological follow-up, these recommendations were not implemented. A prior alleged hanging attempt two weeks befor…

psychiatrypsychologydiagnosticcommunication
WAmental health2019-12-20

Inquest into the Death of Jason James Sutherland MALLETT

46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis

Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient…

psychiatrycardiologysystemcommunicationquetiapine
QLD2023-09-19

AJO - findings

34y · Male·Hanging

… or cell checks. Staff response to discovery was appropriate. The key clinical lesson concerns recognising acute psychological crisis in custodial settings, particularly when facing new charges for serious offences comb…

psychiatrycorrectional healthcannabis
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

…obvious deterioration. While the underlying cause was lethal methamphetamine toxicity with sympathomimetic crisis, the paramedics' failure to provide high-flow oxygen, appropriate airway support, and proper monitoring co…

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
NSWhome2023-09-08

Inquest into the death of BW

31y · Male·hanging

… Key learning: police and DCJ require formal collaboration, improved guidance on recognising mental health crisis in removal contexts, and protocols for supporting distressed parents during child removals.

paediatricspsychiatrycommunicationsystemalcohol
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

…review in custody, and the limitations of risk assessment in newly incarcerated first-time offenders under acute psychological distress.

psychiatrycorrectional healthcommunicationsystemmirtazapine
QLDhome2026-04-21

Inquest into the deaths of F and M

33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…

F and M, two parents involved in family law proceedings over their three children, both died in a house fire in March 2022. F (aged 33) died from extensive burns after M (aged 31) deliberately splashed him with petrol an…

psychiatrypaediatricsdiagnosticsystem

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