Coronial

654 results for mental health issues

VIChome2019-10-07

Finding into death of Tre Leigh Lawson

21y · Male·Hanging

…d by hanging following a tumultuous relationship involving family violence, substance abuse, and unmanaged mental health issues. He had attempted self-harm in May 2017 and was assessed as low imminent risk but never enga…

psychiatryemergency medicinecommunicationsystemmethamphetamine
TAShospital2021-02-05

Coroner's Finding: Lattimer, Joseph Aaron

37y · Male·hypoxic encephalopathy due to asphyxia from hanging

…attimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring assessment within…

emergency medicinepsychiatrysystemdelayalcohol
NSWcommunity2022-10-13

Inquest into the death of Dennis Ellis

34y · Male·Multiple Blunt Force Injuries

…d no causal link between police actions and the death. Clinical lessons include recognizing that untreated mental health issues combined with alcohol dependence and recent stressors significantly increase risk of impulsi…

alcohol
NSW2020-10-27

Inquest into the death of Mikael FELSCH

29y · Male·Unascertainable - likely drowning or accidental injury during terrain navigation…

…mi National Park after becoming stranded in bushland. He had a significant history of suicide attempts and mental health issues exacerbated by methylamphetamine use. On the day of death, he sent messages to family sugges…

psychiatryemergency medicinemethamphetamine
VIC2011-10-20

Finding into death of Jeremy Edward Chandler

49y · Male·Acute blood loss from a single incised injury to left forearm

…ritical first 72 hours—the highest-risk period for prison suicides. The coroner identified that adjustment issues and stress from his predicament likely manifested over this short timeframe but were not monitored. While …

psychiatrycorrectional healthdiagnosticcommunication
NSWhome2023-08-08

Inquest into the death of Atilla Demirer

61y · Male·Could not be determined on the available evidence

…e. The deceased was socially isolated with minimal recent contact from friends or family, had a history of mental health issues following military service, and no ongoing medical care. The coroner could not establish eit…

pathologyforensic medicine
VIChome2014-11-28

Finding into death of Stephanie Jean Winberg

18y · Female·Compression of the neck in circumstances of hanging

…estructive nature of bullying, which Stephanie's family identified as a key stressor alongside her complex mental health conditions. The finding highlights need for improved suicide prevention frameworks, media response …

psychiatrypsychologyfluoxetine
VIChome2018-07-10

Finding into death of Shrihan Gannaram

0y · Male·Multiple injuries sustained from impact with the ground from an extended height …

…riencing postpartum depression and social isolation (with only one friend in Australia), had no identified mental health issues at the four-week postnatal check. She died by suicide within days of the child's death. The …

paediatricsobstetricssystem
VICcommunity2017-02-20

Finding into death of Finding Peter Graham Chaucer

48y · Male·Injuries sustained when struck by a train

A 48-year-old man with mental health issues including depression and possible bipolar disorder died by suicide following train strike. H…

psychiatryemergency medicinecommunicationsystemlithium
VIChome2011-10-18

Finding into death of Lynette Ann Kent

52y · Female·Multiple stab injuries

…ving she could manage Peter. Her GP was unaware of domestic violence concerns. Peter's GP had no record of mental health issues despite his critical deterioration. The coroner's systemic review highlights failures in: ea…

general practiceemergency medicinecommunicationsystem
TAS2021-09-17

Coroner's Finding: Infant Deaths

varied: sudden unexpected death in infancy (unsafe sleeping environment); drowni…

…ilure to recognize cumulative harm, weak safety planning, and poor internal communication. Common clinical issues included unsafe infant sleeping environments (co-sleeping, unsafe bedding), inadequate parental engagement…

paediatricspsychiatrydiagnosticcommunicationalcohol
SAhome2019-10-29

Coroner's Finding: LATTUCA Christophe Thomas Bruno

34y · Male·neck compression due to hanging

A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services …

general practicepsychiatryalcohol
NSWcommunity2017-04-27

Inquest into the death of Anthony FAHEY

29y · Male

…st seen on 3 July 2013 in Canberra after purchasing a bus ticket to Sydney. He was grappling with personal issues including alcohol use, mental health concerns, and existential questions about life, religion, and spiritu…

general practicepsychiatrycannabis
WAhome2024-09-11

Inquest into the Death of Stephen Kenneth SHERWOOD

31y · Male·ligature compression of the neck (hanging)

Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted sui…

psychiatryemergency medicinecommunicationmethamphetamine
NSWhome2023-04-26

Inquest into the death of Trudy Michelle Dreyer

49y · Female·Multiple shotgun wounds to the chest and back of head

…tion and de-escalation strategies. Telephone records from 18 September show conversations centred on trust issues. The partner failed to attend work on 18 and 19 September. Police discovered both deceased individuals at …

VIChome2025-02-27

Finding into death of Shayn Nathan Darmanin

43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…

…lanzapine, and duloxetine. He had a significant history of substance abuse, family violence offending, and mental health issues. His death was the unintended consequence of intentional drug use. Key clinical lessons incl…

toxicologypsychiatrymethadone
VIChome2025-08-13

Finding into death of Lillian Rose Thomas

21y · Female·Compression of the neck secondary to hanging

…ian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a histo…

psychiatrygeneral practicesystemdelayprazosin
ACT2017-12-22

AN INQUEST INTO THE DEATH OFANDREW NOLAN CHRISTIE

37y · Male·asphyxia due to oxygen deprivation secondary to inhalation of helium

…y clinical lessons: (1) Military veterans with untreated PTSD and relationship breakdown require proactive mental health assessment and support, even when they deny issues; (2) The escalating national problem of helium-a…

VIChome2023-02-22

Finding into death of Anna Lawrence

64y · Female·Combined toxicity to alcohol and baclofen

…o evidence that any clinician's conduct contributed to her death. However, the finding highlights systemic issues: baclofen lacks TGA approval for alcohol use disorder despite widespread off-label prescribing in Australi…

psychiatrypsychologysystembaclofen
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 Janua…

emergency medicinepsychiatrysystemdelay

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