Coronial

35 results for adjustment disorder in custody

QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

…The case highlights challenges in predicting suicide risk, the importance of timely psychiatric review in custody, and the limitations of risk assessment in newly incarcerated first-time offenders under acute psychologi…

psychiatrycorrectional healthcommunicationsystemmirtazapine
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…

psychiatrygeneral practicesystemcommunicationmirtazapine
NSW2023-05-23

Inquest into the death of JS

34y · Male·Plastic bag asphyxia

A 34-year-old man on remand died by plastic bag asphyxia at Shortland Correctional Centre on 5 May 2020, hours before his release on bail. He had disclosed anxiety and depression, made multiple self-referrals for mental …

psychiatrypsychologydiagnosticcommunication
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

…d was subsequently treated with antidepressants and psychiatric care, achieving stability. Upon remand in custody in December 2019, Justice Health obtained limited medical records that omitted his psychiatric history, t…

psychiatrygeneral practicecommunicationsystemsertraline
NSWprison2023-07-14

Inquest into the death of GS

43y · Male·Hanging

GS, a 43-year-old man with complex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in Goulburn Correctional Centre after 183 days in custody. The critical …

psychiatrygeneral practicediagnosticcommunicationsertraline
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

…ea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girlfriend. Prior psychiatric assessment at Graylands Hospital …

psychiatrycorrectional healthcommunicationsystemantidepressants
WA2023-12-21

Inquest into the Death of Shane Nathan ROBERTS

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

Shane Nathan Roberts, aged 41, died by ligature compression (hanging) in Hakea Prison on 24 June 2019. He had pre-existing depression and anxiety treated with citalopram. A prison doctor referred him to the Mental Health…

correctional healthgeneral practicesystemdelaycitalopram
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

Boe Luke Memery, a 24-year-old Aboriginal man, died by hanging on 19 May 2019 following a relationship breakdown. He had a history of depression, self-harm, and previous suicide attempts. In the weeks before his death, h…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

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

Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management includ…

psychiatrypsychologydiagnosticsystemmethamphetamine
WAmental health2000-08-18

Inquest into the Death of Wendy Anne Eadie

29y · Female·asphyxiation due to ligature compression of the neck (hanging)

Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…

psychiatryforensic medicinecommunicationsystemparoxetine
SA2006-10-18

Coroner's Finding: TURNER Barry Michael and GLENNIE Troy Michael

Neck compression due to hanging (self-inflicted)

Two men, Barry Michael Turner (35) and Troy Michael Glennie (28), died by hanging in Adelaide Remand Centre while on remand. Both had expressed suicidal ideation and were being monitored via 'yellow sheet' daily nursing …

psychiatrycorrectional healthsystemcommunicationquetiapine
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy ca…

neurologypsychiatrydiagnosticcommunicationvigabatrin
QLD2018-05-16

Houdini, Franky

41y · Male·Hanging

Franky Houdini, aged 41, died by hanging in his prison cell at Wolston Correctional Centre on 2 June 2015. He was subject to an involuntary treatment order for paranoid schizophrenia and was undergoing dangerous prisoner…

psychiatrycorrectional healthcommunicationsystemrisperidone
SA2006-09-25

Coroner's Finding: BROOKS Neil James and FOSTER Tracy Jayne

43y · Male·suffocation by plastic bag (Neil Brooks); neck compression due to strangulation …

Two deaths investigated in joint inquest: Tracy Jayne Foster died by strangulation in December 2002; Neil James Brooks, her partner charged with her murder, died by suffocation while on remand in May 2003. The coroner id…

psychiatrycorrectional healthcommunicationsystemzopiclone
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

…es despite victim repeatedly expressing fear. Ms Bradford was never informed of her abuser's release from custody. Better integrated safety planning, victim-centred risk assessment, and information sharing could have im…

general practicepsychiatrycommunicationsystemwarfarin

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