36y · Male·Hypoxic/ischaemic encephalopathy and hanging
… 2013 and died 3 days later at Northern Hospital from hypoxic-ischaemic encephalopathy. He had experienced major life stressors including business failure, relationship breakdown, serious pending criminal charges, and a…
3y · Male·smothering
A 3-year-old boy died from smothering by his mother, who was suffering from severe bipolar affective disorder with psychotic features and severe depression. The coroner examined whether psy…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suici…
82y · Female·acute pyelonephritis complicating base of bladder malignancy
Joyce Binch, 82, died of acute pyelonephritis from bladder malignancy while detained under mental health legislation. She was admitted with urinary tract infection, anaemia, acute renal failure, and acute exacerbation of…
81y · Female·ischaemic bowel
An 81-year-old woman with longstanding depression and multiple comorbidities fell and fractured her humerus in March 2009. During rehabilitation, she beca…
90y · Male·aspiration pneumonia complicating community acquired pneumonia
…after Guardianship Board approval, with initial mood improvement but no physical improvement. He developed severe hypoxaemia and died on a palliative care pathway. The coroner found care was appropriate and detention law…
56y · Female·acute pentobarbitone toxicity
…tone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health issues, depression, substance use, and prior self-harm. She had recently obtained pentobarbitone from Mexico via internet, …
50y · Female·mixed tablet overdosage (quetiapine and venlafaxine with codeine)
…ne) following a progressive mental health decline. After work-related stress in late 2002, she developed depression and anxiety. While individual clinicians provided reasonable care, the coroner identified critical syste…
54y · Female·Acute alcohol toxicity with immersion
A 54-year-old woman with major depressive disorder and alcohol addiction died from acute alcohol toxicity with immersion. She was hospita…
26y · Male·unascertained; suspected suicide by firearm
…rm in regional Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 2009, including paranoid ideation and command hallucinations suggesting suicide. He wa…
56y · Male·unascertained; presumed suicide by unknown means
Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 S…
52y · Male·hanging
A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requeste…
39y · Male·Drowning in the setting of a very high blood alcohol level
…ery high blood alcohol level (0.33g/100mL). He was not a confident swimmer and had a history of anxiety, depression, and alcohol misuse. He had ceased psychological treatment due to financial difficulties and did not eng…
45y · Male·unascertained
…red from Petrudor Rocks National Park on 10 November 2011 and is presumed dead. He had a long history of depression, suicidal ideation, and previous suicide attempts by hanging and overdose. He was sexually abused as a t…
54y · Male·Extensive burns due to detonation of LPG gas cylinder
A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence…
86y · Female·Plastic bag asphyxia
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care…
77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression
77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission…
38y · Female·Multiple injuries sustained when struck by a train
…ng complaint. This mishandling, combined with ongoing physical pain and workplace distress, contributed to severe major depression. Despite attendance at emergency department in March 2021, no adequate psychiatric assess…
31y · Female·drowning, deliberately self-inflicted with intention of ending life
Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 …
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of …
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