Coronial

92 results for acute suicidal behaviour

VIChome2023-01-17

Finding into death of Steven John Bamblett

29y · Male·Hanging

…nce Intervention Order application. He had a documented history of untreated mental illness with frequent suicidal ideation, suspected ADHD, and repeated self-harm behaviour during family violence incidents. Critical fai…

psychiatryforensic medicinecommunicationsystemcannabis
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

…rom a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideation and substance dependence issues. Key clinical lessons: (1) The family meeting on 16 December bec…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NTmental health2009-04-09

Inquest into the death of Paul Guarini

38y · Male·self-inflicted hanging

…nvoluntary mental health patient. He had presented to hospital multiple times over 4 days with escalating suicidal behaviour, including a dramatic attempted hanging on 10 September while intoxicated (0.18% BAC). On 14 Se…

psychiatryemergency medicinediagnosticsystemparoxetine
VIChome2011-10-18

Finding into death of Lynette Ann Kent

52y · Female·Multiple stab injuries

…ention. Despite multiple warning signs—Peter's documented history of violence, stalking, and controlling behaviour; explicit threats to kill Lyn and her new partner; and a suicide noose discovered days before—no protect…

general practiceemergency medicinecommunicationsystem
SA2013-05-29

Coroner's Finding: RICHARDS Jason Neil

28y · Male·gunshot injury of head, self-inflicted

…minimal rest. Witnesses observed him displaying erratic driving, paranoia, hallucinations and delusional behaviour consistent with methamphetamine intoxication on 21 June 2011. These sightings were not reported to polic…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

…nging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicidal ideation and a reported self-harm attempt. Despite appropriate i…

psychiatryemergency medicinecommunicationsystemaripiprazole
SAhospital2011-10-06

Coroner's Finding: BROWN Kunmanara

18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hangi…

…hypoxic brain injury following cardiac arrest from hanging. He had a chronic petrol-sniffing habit and was acutely intoxicated on petrol when he hanged himself after a police incident. Police responded appropriately to …

emergency medicineintensive carecommunicationsystempetrol
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)

…f reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckless driving (190 kph). Dr W. prescribed an antidepressa…

general practiceemergency medicinediagnosticcommunicationcitalopram
NSWmental health2019-06-04

Inquest into the death of Andrea Sewell

46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…

Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychia…

psychiatryneurologyantipsychotic medications
WA2016-11-04

Inquest into the Death of Simon John ROWE

37y · Male·multiple injuries in a man with methylamphetamine effect (suicide by jumping fro…

Simon John Rowe, a 37-year-old man with a history of drug use and imprisonment, died by suicide on 12 April 2012 after deliberately jumping from a 12th-floor hotel window during a police siege. He had smashed the window,…

emergency medicinepsychiatrymethamphetamine
VIChome2014-02-12

Finding into death of Sibel Yilmaz

24y · Female·hanging

A 24-year-old woman with longstanding depression, anxiety, and a history of self-harm and suicidal ideation died by hanging following a marital conflict. She had been under care of university counsellors …

psychologypsychiatrycommunicationsertraline
SAmental health2025-03-06

Coroner's Finding: Fowles, Wayne Lincoln

59y · Male·hanging

…e open ward after clinical review. Despite 30-minute observations initiated due to concerning night-time behaviour, he absconded on 19 October 2021 and died by hanging two days later. The coroner found the clinical mana…

psychiatryemergency medicinelorazepam
VIC2026-02-03

Finding into death of Jacqueline Courtenay Hunter Pringle

23y · Female·Injuries sustained in a fall from a height

… 2018 after her clinician noted she appeared substance-affected at her final review but had no documented suicidal ideation. Key clinical lessons include the importance of recognising substance intoxication during psychi…

psychiatrypsychologycommunicationdiagnosticalcohol
WAhospital2013-02-14

Inquest into the Death of Marshall, Tracy Margaret

54y · Female·unascertainable

…aret Marshall was a 54-year-old woman admitted to Nickol Bay Hospital on 20 February 2011 after reporting suicidal ideation and three suicide attempts. She presented with signs of psychotic illness including bizarre beha…

psychiatryemergency medicinediagnosticcommunicationdiazepam
SAhospital2019-06-12

Coroner's Finding: HARRAP Jean

82y · Female·bilateral pulmonary thromboembolism due to left calf deep vein thrombosis

…ental Health Act Inpatient Treatment Order. She presented to ED with altered mental state, self-harm, and suicidality. Investigations (bloods, CXR, CT) were normal. She was appropriately detained for psychiatric assessme…

psychiatryemergency medicineparoxetine
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

…admissions and the patient's initial treatment reluctance; Perth Children's Hospital appropriately managed acute presentations but faced a significant service gap—there was no step-up/step-down facility available betwee…

psychiatryemergency medicinesystemdelaysertraline
VICmental health2013-02-25

Finding into death of Joy Apostolopoulos

41y · Female·Multiple injuries due to impact by train

…after absconding from a locked psychiatric ward at Alfred Hospital. She had been on escorted leave, became acutely agitated upon returning home, and was brought back to the ward by ambulance at 7:31pm. Critical failures…

psychiatryemergency medicinecommunicationsystemclozapine
VICmental health2016

Finding into death of Rebecca Victoria Poke

29y · Female·global cerebral ischaemic injury in the setting of neck compression

Rebecca Poke, a 29-year-old woman with borderline personality disorder, died by suicide while an inpatient in Ward E of Casey Hospital on 2 September 2015. She had been admitted following a paracetamol overdose and was o…

psychiatryintensive caresystemvenlafaxine
QLD2021-09-20

Harris, John Edward

47y · Male·Hanging

…anging point. While staff noted his usual presentation included irritability and social withdrawal, making acute risk harder to discern, the Office of the Chief Inspector identified that his behaviour in preceding weeks…

correctional healthpsychologyassessmentsystemcarbamazepine
WAcommunity2016-09-13

Inquest into the Death of Anthony Charles EURA

42y · Male·unascertained

…ar-old Aboriginal man with long-standing mental health problems, alcohol and drug dependency, and chronic suicidality, disappeared in November 2006 and is presumed deceased. In the month before disappearance, he presente…

psychiatryemergency medicinesystemdiagnosticfluphenazine

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