22y · Male·Neck compression by ligature suspension (hanging)
…thdrawal, particularly after returning from India in March 2020. He told his mother he felt stressed and depressed in late 2019, but received only brief counselling while in India. Upon returning to Australia, he became…
50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)
Treenor Heather Randall, a 50-year-old registered nurse, died from mixed tablet overdose (quetiapine and venlafaxine) following a progressive mental health decline. After work-related stress in late 2002, she developed d…
34y · Male·hanging
John Sydney Farmer, aged 34, died by hanging at his home on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days e…
24y · Male·hanging
Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…
25y · Male·drowning
Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …
33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes
A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…
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…
33y · Male·Self-inflicted hanging
… attempts. In the days before his death, fellow prisoners observed concerning changes: loss of appetite, depressed mood, withdrawal, and destruction of his girlfriend's letters and photographs. A relationship breakdown …
50y · Male·Multiple injuries as a result of being struck by a train
A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he attended work while intoxicated following personal stress, l…
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…
24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)
Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckle…
36y · Male·multiple injuries consistent with a fall from a height
A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…
32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…
Michelle Darragh, a 32-year-old social worker, was fatally stabbed by her former partner Benjamin Coman on 9 October 2021. She was pregnant with their third child. The relationship involved progressive coercive control, …
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
26y · Male·self-inflicted gunshot wound to the head while suffering severe depression
…ill, a 26-year-old NSW police officer, died by self-inflicted gunshot wound in March 2009 while severely depressed. Over 20 months prior to death, he experienced escalating mental health difficulties with work absences …
48y · Male·hanging, intentionally self-inflicted
SS, a 48-year-old male with treatment-resistant depression and chronic suicidal ideation, died by hanging in Boronia Park, NSW in June 2014. He was admitted to Gosford Hospital Mental Health Unit in late May 2014 as an i…
18y · Female·Mixed drug toxicity
Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally overdosing on proprano…
30y · Male·ligature compression of the neck (hanging)
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…
20y · Male·hanging
…he order and discharged him, based on apparent clinical improvement, though his sister noted he remained depressed. Following discharge, the patient exhibited volatile mood, suicidal ideation, overdosed on antidepressan…
72y · Female·Hanging
…on management orders. The case highlights the risks when clinical mental health assessment is omitted in depressed, isolated patients facing significant physical suffering and separation from family support, particularl…
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