Coronial

308 results for family crisis

VIChome2021-12-17

Finding into death of B H

49y · Male·hanging

… a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that his daughter had allege…

psychiatrypsychologycommunicationsystemantidepressant medication
NSWhome2020-06-05

Inquest into the death of BG

30y · Male·neck compression from ligature strangulation and possible suspension (hanging)

… suicidal ideation. Clinical lessons centre on recognising clusters of psychosocial risk factors—financial crisis, relationship breakdown, substance abuse history, and expressed hopelessness—as warning signs for imminent…

psychiatryemergency medicinedelay
QLDcommunity2024-08-21

Inquest into the deaths of Charmaine, Aaleyn, Matilda, Wyatt, and Zaidok McLeod

Female·multiple injuries from motor vehicle collision (for all five deceased)

…rns, and custody disputes. The crash occurred following an emotionally distressing email exchange with her family law solicitor on 27 May 2019. Contributing factors included her untreated mental health conditions, high s…

psychiatryemergency medicinesystemcommunicationfluvoxamine
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

…chiatrist failed to maintain contemporaneous clinical notes in the electronic system, rarely contacted her family or GP despite warning signs including suicidal ideation, and provided inadequate crisis support. The coron…

psychiatrygeneral practicecommunicationsystemrisperidone
TAS2015-10-30

Coroner's Finding: Mr S

43y · Male·multiple injuries due to motor vehicle collision with a tree

…nsequences. This case highlights the importance of mental health assessment and support for individuals in crisis facing criminal charges, and the limitations of police negotiation when someone is determined to end their…

forensic medicineemergency medicine
NSWhome2021-04-16

Inquest into the death of WW

Male·gunshot wound to the head, intentionally self-inflicted

…ril 2021 with findings delivered on 16 April 2021. Publication of material identifying the deceased or his family was restricted under Section 75 of the Coroner's Act 2009. This case represents a tragic outcome of an app…

psychiatryemergency medicinecommunicationsystem
VIChome2020-09-28

Finding into death of JC

17y · Male·Hanging

…empt, and escalating aggressive behaviour died by hanging shortly after being excluded from his home via a Family Violence Intervention Order (FVIO). He was arrested for family violence involving a weapon at 1:45am and r…

psychiatryemergency medicinesystemcommunicationdiazepam
VIChospital2014-05-14

Finding into death of Palma Castro

26y · Female·compression of the neck consequent upon hanging

…ours on 17-18 February 2011. She presented following a suicide attempt with overdose and was discharged to family care without admission despite clear suicidality indicators. Clinical lessons include: risk assessment too…

psychiatryemergency medicinecommunicationdocumentationalprazolam
ACTmental health2015-06-15

AN INQUEST INTO THE DEATH OF PETER ZOVAK

46y · Male·asphyxia by hanging

…er died by suicide on 18 December. While the coroner found the service failed to respond adequately to the crisis call, causation could not be established. Key lessons: assess calls reporting psychotic symptoms thoroughl…

psychiatryemergency medicinediagnosticcommunicationcannabis
VIChospital2022-04-11

Finding into death of C J

22y · Male·Hanging

…5 January after being assessed as medium risk. Critical gaps included: lack of collateral information from family during assessment, no explicit exploration of his disclosed hanging plan, inadequate alcohol counselling d…

emergency medicinepsychiatrycommunicationsystemdiazepam
VIC2016-05-25

Finding into death of Umut Selek

23y · Male·Unascertained

…acute agitation, aggression, and unusual strength after what appears to be a mental health or drug-related crisis. After a 20-minute restraint involving multiple officers at a police station, he was sedated with 5mg intr…

forensic medicineemergency medicinecommunicationsystemmidazolam
WAcommunity2026-03-13

Inquest into the Suspected Death of PARBHAT

24y · Male·unknown cause

…ned (injury or drowning), the coroner concluded he died by suicide based on compelling evidence: financial crisis, employment loss, visa jeopardy, social isolation, heavy alcohol use, and cultural fear of returning home …

alcohol
QLDcommunity2016-01-18

Kumeroa, Shaun Basil

42y · Male·gunshot wounds to the chest and abdomen

Shaun Basil Kumeroa, aged 42, died from gunshot wounds during a police siege in Brisbane. Following a family dispute resolution conference regarding custody of his daughter, Mr Kumeroa assaulted his ex-partner and b…

general practicepsychologybuprenorphine/naloxone
WAcommunity2017-02-28

Inquest into the Death of Colin John JOHNSTON

46y · Male·Unknown - possible causes include traumatic injury or dehydration in remote terr…

… health struggles (depression, alcoholism), remote and harsh terrain, lack of any contact with services or family since disappearance, and explicit suicidal communications. The clinical lessons centre on recognition of a…

NSWcommunity2023-11-17

Inquest into the death of SB

51y · Male·Stab wounds to the chest

…ts this would not have changed the outcome. (2) Police should have gathered more detailed information from family members, who knew SB's history and recent self-harm allegations better than anyone. (3) The decision-makin…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWcommunity2016-03-24

Inquest into the disappearance and suspected death of Peter Millett

45y · Male·unable to determine

… that medication non-adherence would worsen psychotic symptoms and increase suicide risk. Although Peter's family and treating doctor initiated contact and attempted to arrange medical review, Peter refused help. No body…

general practicepsychiatryzyprexia
VICmental health2015-10-15

Finding into death of Helen Maria Bryce

54y · Female·Hanging

…ays of treatment and progressive day leave, she was approved for two nights of overnight leave escorted by family. During this leave, she died by hanging. The coronial investigation found significant process failures: th…

psychiatrygeneral practicecommunicationsystemcitalopram
NSWcommunity2024-11-26

Inquest into the death of Andrew Chee Quee

51y · Male·gunshot wound to the chest

Andrew Chee Quee, 51, died from a gunshot wound sustained during a police confrontation at Bay Street, Rockdale, on 20 April 2020. He had a longstanding history of depression, substance abuse, and suicidal ideation. On t…

psychiatrypsychologyalcohol
VIChome2025-11-24

Finding into death of Suk Ching Annie Ng

64y · Female·Blunt Force Trauma to the Head in the Setting of Prolonged Lie; Metastatic Breas…

…ling can escalate to intimate partner homicide, with financial deception, loss of trust, and psychological crisis as contributing factors. Annie's cancer treatment was interrupted due to financial conflict. Early interve…

oncologygeneral practicesystem
VICcommunity2013-01-31

Finding into death of Stuart Beverley

31y · Male·Hanging

…empt on 30 March 2005, discharged after psychiatric assessment at Maroondah Hospital ED. Following several crisis presentations over the next week, he was briefly admitted involuntarily on 3 April 2005 but discharged the…

psychiatryemergency medicinecommunicationdelaydiazepam

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