Coronial

390 results for mental health deterioration

SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

…resented with stroke-like symptoms in March 2012. Neuroimaging was unrevealing. She was detained under the Mental Health Act due to concerns about oral intake and anticipated non-cooperation with treatment. Despite appro…

neurologypsychiatry
NSWcommunity2015-02-20

Inquest into the disappearance and suspected death of Margery Joyce TAYLOR

50y · Female·unascertained

…nner of death, though noted possibilities including drowning in flood waters or deliberate self-harm while mentally unwell. Clinical lessons: importance of medication adherence monitoring post-discharge, recognition of a…

psychiatrygeneral practicesystemdelay
NSWcommunity2016-03-24

Inquest into the disappearance and suspected death of Peter Millett

45y · Male·unable to determine

…nia, disappeared on 27 August 2013 and is presumed deceased. In the weeks preceding his disappearance, his mental health deteriorated significantly—he exhibited rapid speech, paranoid ideation about conspiracies, and app…

general practicepsychiatryzyprexia
SAhospital2002-05-17

Coroner's Finding: MITTA Wilhelmina

88y · Female·sepsis of unknown origin

An 88-year-old woman with multi-infarct dementia and behavioural disturbance was detained under the Mental Health Act following assault of her GP. She presented with abdominal symptoms and deteriorating vital sign…

geriatric medicinepsychiatrydiagnosticanti-psychotic medication
NSWcommunity2023-09-05

Inquest into the death of Daniel Bolton

30y · Male·Gunshot wound to the neck and head

…wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and suicidal ideation, and substantial criminal history. Durin…

psychiatrygeneral practicesystemcommunicationcannabis
VIChospital2025-04-11

Finding into death of QB T

64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…

…OPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deterioration. During his 8-day admission, he developed progressive shortness of breath, hypoxia, a…

psychiatrygeneral medicinediazepam
VIChospital2011-10-26

Finding into death of John Threadgold

55y · Male·Cardiopulmonary arrest, respiratory failure and chronic obstructive airways dise…

…l abuse, died from cardiopulmonary arrest and respiratory failure. He was admitted involuntarily under the Mental Health Act in July 2010 and transferred to a Prevention and Recovery Care unit. His condition deteriorated…

psychiatryemergency medicinecommunicationsystemantipsychotic medications
WAcommunity2026-05-27

Inquest into the Death of David GRAY

58y · Male·Gunshot injury to the abdomen

David Gray, 58, deliberately induced police to shoot him as a means of suicide following undisclosed mental health deterioration. On 22 September 2023, he called police anonymously reporting an armed person, then p…

emergency medicineforensic medicine
VICcommunity2016-09-06

Finding into death of Antonio D'Augello

63y · Male·Drowning

…ing antipsychotic medication in March 2016. During a collapse on 28 April, he was taken to Goulburn Valley Health ED where he was assessed as psychotic with poor insight but medically stable and discharged home with an o…

psychiatryemergency medicinecommunicationdelayolanzapine
TAShospital2022-12-15

Coroner's Finding: Mather, Robert Andrew

80y · Male·asphyxia due to choking on food

…ry retention. He had schizophrenia with 40+ year history and poor compliance off medications. Clinical deterioration was profound: 3-week religious fasting causing significant weight loss, unattended for 5+ years by GP,…

psychiatrygeriatric medicineantipsychotic medications
QLDhome2011-03-25

Clarke, Daniel James

36y · Male·Gunshot wound to the forehead

A 36-year-old man with a 10-year history of forensic mental health order died by gunshot wound during a siege after police arrived to enforce psychiatric hospitalisat…

psychiatrycorrectional healthcommunicationsystem
SAhospital2015-08-13

Coroner's Finding: ABINETT Murray Lawrence

81y · Male·Aspiration pneumonia complicating end stage fronto-temporal dementia on a backgr…

…nic obstructive lung disease, ischaemic heart disease and chronic renal failure. He was detained under the Mental Health Act following behavioural deterioration after medication changes (cessation of risperdal). During a…

psychiatrygeriatric medicinediagnosticrisperidone
QLDhome2009-03-16

Blake, Melissa Maree

Female·Drowning (suicide)

…ment for psychotic depression, which developed following a miscarriage. She was referred to Sunshine Coast Mental Health Services and received treatment with antidepressants and antipsychotics, with daily monitoring by p…

psychiatrygeneral practicemedicationcommunicationescitalopram
WAcommunity2024-12-06

Inquest into the death of Jaxon Charles Kinnane

22y · Male·Immersion in water (drowning) in a man with combined drug effect

…tre, and St John of God Midland Hospital. While clinicians provided appropriate care within constraints of mental health law and his voluntary patient status, several missed opportunities were identified: Dr M. did not r…

psychiatrycorrectional healthcommunicationsystempaliperidone
QLDhome2014-07-18

Bowling, Dianne Judith

59y · Female·Mixed drug toxicity, with metoprolol at toxic level; coronary atherosclerosis as…

…volving a toxic level of metoprolol. She had a history of three previous overdoses and was under community mental health services. In October 2011, community workers noted signs of deterioration (anxiety, insomnia, emoti…

psychiatrygeneral practicecommunicationsystemmetoprolol
SAhospital2011-09-23

Coroner's Finding: BLYTHE Dorothy Josephine

81y · Female·ischaemic bowel

…nd self-neglectful, refusing food and cooperation with therapy. She was admitted to psychiatric care under Mental Health Act detention. On 9 May 2009, her physical health acutely declined with shock-like symptoms. Emerge…

psychiatrygeneral surgerydiagnosticdelay
NSWhome2026-05-06

Inquest into death of Laila Philip Samson Lado

30y · Male·unascertained

…relationship broke down with his partner relocating to Melbourne with their child. He experienced apparent mental health decline evidenced by crying episodes, paranoia about home break-ins, and assertions of anxiety/pani…

VICcommunity2019-07-30

Finding into death of Caterina Fratto

45y · Female·Hanging

…sa and depression died by hanging. She had chronic suicidal ideation and was managed in the community by a mental health team despite expressing active suicidal thoughts in the days before her death, including a recent o…

psychiatrygeneral practicecommunicationdocumentationquetiapine
VIChome2016-04-04

Finding into death of Jacinta Pompei

32y · Female·Blunt force trauma to the head

…edly with a claw hammer while she slept. The coroner investigated whether her death was preventable from a mental health perspective. Mr Ellard had treatment-resistant paranoid schizophrenia and was under voluntary menta…

psychiatryforensic medicineclozapine
NSWhome2023-07-05

Inquest into the death of JY

5y · Male·multiple stab wounds

…father, diagnosed with schizophrenia in 2003, was admitted to Hornsby Hospital in April 2018 following deterioration. His medication was changed from risperidone depot to aripiprazole depot during admission, with quetia…

psychiatrygeneral practicecommunicationsystemrisperidone

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