Coronial

61 results for acute suicidality

VIChome2020-04-23

Finding into death of Baillee Petra Schneider

25y · Female·Compression of the neck

…nzodiazepine presence. The coroner found no suspicious circumstances. Key clinical lessons: recognize that acute intoxication combined with benzodiazepines, antidepressants, and cocaine significantly impairs judgment an…

psychiatrytoxicologyalcohol
SAhospital2019-06-12

Coroner's Finding: HARRAP Jean

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

…tal 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 assessmen…

psychiatryemergency medicineparoxetine
VICmental health2015-02-02

Finding into death of CB

27y · Female·hanging

…isorder died by hanging while voluntarily admitted to a psychiatric inpatient unit. She had presented with acute suicidality following relationship breakdown and job loss, with two recent suicide attempts including hang…

psychiatryemergency medicinediagnosticcommunicationquetiapine
VICcommunity

Tylercassidypart2 554208

Male·Multiple gunshot wounds from police shooting

…ing as at December 2008. Police had received inadequate training in recognizing vulnerable young people in acute psychiatric crisis, conducting effective risk assessment, or using evidence-based de-escalation techniques…

psychiatrycommunicationsystemalcohol
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but…

psychiatryemergency medicinesystemdelaymirtazapine
TAScommunity2022-01-28

Coroner's Finding: AZ 2022 TASCD 60

16y · Male·Multiple blunt traumatic injuries from fall from height

A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had previous…

psychiatrycommunicationdiagnosticfluoxetine
VIChospital2022-04-11

Finding into death of C J

22y · Male·Hanging

…plan, inadequate alcohol counselling despite documented increased alcohol use associated with worsening suicidality, and delayed communication of assessment findings to the receiving crisis team (faxed 3+ hours after di…

emergency medicinepsychiatrycommunicationsystemdiazepam
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…

psychiatrygeneral practicediagnosticsystemmethylphenidate
NSWcommunity2020-06-10

Inquest into the death of Christopher McGRAIL

44y · Male·Gunshot wounds to the trunk and right thigh with subsequent blood loss

…trauma following his son's suicide, was shot by NSW Police during a knife confrontation. He presented with acute intoxication (alcohol and methamphetamine), substance-induced psychotic episode, paranoid delusions about …

emergency medicinepsychiatrymethamphetamine
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 Hospital under inv…

psychiatrydiagnosticcommunicationtemazepam
NSWmental health2022-02-01

Inquest into the death of Camilla MARGOLIS

34y · Female·multiple blunt force injuries

…scharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 20+ hospital admissions over several years. Critical clinical lessons emerged: (1) Fragmentation…

psychiatryemergency medicinecommunicationsystemmirtazapine
VICcommunity2015-05-29

Finding into death of Craig Doherty

49y · Male·Multiple injuries from a fall from height

…icidal ideation and appeared calm to multiple clinicians and police. Critical clinical lesson: Patients in acute manic relapse with paranoid delusions, medication non-compliance, and recent substance use require careful…

psychiatrygeneral practicelithium
VIC2012-07-27

Finding into death of Michael Scott Wyly

41y · Male·hanging

…scharge decisions and suicide risk rating downgrades; (3) lack of structured follow-up post-discharge from acute assessment units; (4) importance of family communication channels. Systems improvements implemented after …

psychiatrycorrectional healthcommunicationsystem
TAShospital1996-10-01

Coroner's Finding: Muller Shar Marie

25y · Female·injuries sustained by jumping from the Tasman Bridge

… to jump from the bridge. Key clinical lessons include the challenges of managing patients with chronic suicidality who refuse assessment, the role of substance intoxication in risk assessment, and the legal limitations…

psychiatryemergency medicinecommunicationsystemflunitrazepam
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involu…

psychiatryneurologyescitalopram
NSWhome2025-07-30

Inquest into the death of Hilary Gordon-Squire

65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…

…care months earlier and subsequent primary care contacts offered adequate assessment for depression and suicidality, given documented depression history and lack of treatment. Better mental health screening and support …

forensic medicinegeneral practicesystemdelaybenzodiazepines
WAhospital2013-02-14

Inquest into the Death of Marshall, Tracy Margaret

54y · Female·unascertainable

…tric assessment and involuntary admission protocols, and importance of secure observation in patients with acute suicidality.

psychiatryemergency medicinediagnosticcommunicationdiazepam
NSWcommunity2021-09-23

Inquest into the death of M F

46y · Male·blunt force injuries from motor vehicle collision with a tree

…ssons include: the critical shortage of immediate access to drug and alcohol rehabilitation for those with acute addiction; the interconnection between substance use, depression, and suicidality requiring integrated tre…

general practicepsychiatrysystemdelayamphetamine
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

…ex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, sertraline, gabapentin, peric…

psychiatrygeneral practicecommunicationsystemtapentadol
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine

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