Coronial

402 results for suicide risk high

VICcommunity2023-08-28

Finding into death of Jorgen Bottern

86y · Male·carbon monoxide poisoning

…t criteria, and discharged to community care with daily follow-up planned. Within three weeks, he died by suicide. Key clinical lessons: (1) older men aged 85+ have the highest suicide rate in Victoria—this demographic …

psychiatrygeneral practicesystem
VICmental health2018-03-13

Finding into death of Elizabeth Anne Palmer

39y · Female·Hypovolaemic shock due to incised injury to the wrist

A 39-year-old woman with a history of mental health issues and previous suicide attempts was admitted to a high-dependency psychiatric unit following a suicide attempt involving razor b…

psychiatryemergency medicineproceduralcommunication
TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

… personality features. Key clinical lessons: (1) Prolonged stays on non-psychiatric wards for patients with high suicide risk require enhanced environmental safety measures including regular searches for means; (2) When …

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
VICmental health2023-06-22

Finding into death of Veronika (Veronica) Anastasia Kouros

31y · Female·Plastic bag asphyxia

…ag and placed it over her head between 6:00-7:00 AM. She had been assessed as not presenting acute suicidal risk the previous evening and was observed asleep at 6:00 AM. The coroner found the death preventable, concludin…

psychiatrygeneral practicesystemproceduralquetiapine
VIChome2013-08-21

Finding into death of Katarina Sonia Novakovic

47y · Female·INCISED INJURY TO THE NECK

… her parents' deaths and increasing social isolation. Two days before her death, a case manager completed a risk assessment and found her stable, denying suicidal ideation, though she reported hopelessness themes. The co…

psychiatrygeneral practicecommunicationdelayolanzapine
TAScommunity2026-02-23

Coroner's Finding: de-identified VY

33y · Female·hanging

… woman with significant history of mental health issues, depression, anxiety, suicidal ideation and prior suicide attempts died by hanging while highly intoxicated (BAC 0.183g/100mL). She used a length of telecommunicat…

psychiatryemergency medicinesystemalcohol
TAScommunity2025-07-04

Coroner's Finding: de-identified KT

26y · Male·multiple injuries, primarily severe chest trauma, due to jumping from the Tasman…

A 26-year-old man with psychosis and acute schizophrenia died by suicide jumping from the Tasman Bridge. He had been diagnosed with ADHD, generalised anxiety disorder, and sleep-…

psychiatryemergency medicinepaliperidone
VICmental health2012-10-12

Finding into death of Grant Elliot Phillips

29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)

Grant Phillips, 29-year-old with schizophrenia and complex psychiatric history including multiple suicide attempts, was admitted involuntarily to Broadmeadows Inpatient Psychiatric Unit on 5 May 2007. Despite be…

psychiatrydiagnosticsystemdextroamphetamine
SAmental health2011-08-26

Coroner's Finding: XU Yan Yi

50y · Female·compression of the neck consistent with hanging

…epression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in her room on 28 December 2008. Critical failures inc…

psychiatrygeneral practicediagnosticcommunicationsertraline
QLD2007-11-29

Mills, Samuel John

31y · Male·Self-inflicted hanging

Samuel John Mills, a 31-year-old man with chronic schizophrenia, died by suicide in Lotus Glen Correctional Centre's medical ward in 2004. Staff provided adequate supervision on the day …

psychiatryemergency medicinesystemcommunicationmelleril
VICcommunity2010-12-02

Finding into death of DUKE MATAKU TERA

19y · Male·Hanging (intentional suicide)

…g on 1 May 2007. Duke had a history of depression, substance abuse, anger management issues, and previous suicide attempts. He was under supervision by the Department of Human Services through Youth Justice following cr…

psychiatrypsychologycannabis
VICmental health2016-12-08

Finding into death of Joseph Pezzimenti

60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression

… Unit bathroom. Key clinical lessons include: communication difficulties (voice loss) should not diminish suicide risk assessment—Dr B.'s assessment of 'no overt risks' despite multiple prior attempts was inadequate; tr…

psychiatryintensive carediagnosticcommunication
VICcommunity2010-05-27

David holland 458408

31y · Male·Multiple injuries in a fall

A 31-year-old male with depression and a history of suicide attempts stopped taking his antidepressant (escitalopram) against medical advice. On 9 October 2008, afte…

alcohol
ACTcommunity2019-10-14

Inquest into the death of Adrian Pitman

54y · Male·Multiple injuries due to motor vehicle collision with retaining wall caused by d…

Adrian Pitman, a 54-year-old man with treatment-resistant schizophrenia, died by suicide following a motor vehicle collision with a retaining wall. He was subject to a psychiatric treatment orde…

psychiatrycommunicationsystemolanzapine
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

…2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days earlier following workplace stress, shoulder injury, loss of driver…

psychiatryemergency medicinediagnosticcommunicationcitalopram
QLDhome2014-07-28

Copeland, Alison Ruth - Non-inquest findings

55y · Female·Plastic bag suffocation

…sical disability and depression since suffering a subarachnoid haemorrhage in 1995. She had made multiple suicide attempts over 16 years. The central clinical issue was the systemic failure to secure appropriate high-ca…

psychiatryneurologysystemdelaytemazepam
VIC2023-12-01

Finding into death of JCS

36y · Female·plastic bag asphyxia

…he was housed in a maximum security prison with appropriate psychiatric oversight, holding an S1 (immediate risk) classification at the time of death. She had access to plastic packaging and cord material from clothing p…

psychiatrypsychologysystem
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

…st 2003 after presenting with wrist lacerations and reported tablet ingestion. She was assessed as moderate risk and placed on 15-minute observations. Dr A. instructed close monitoring and mentioned possible transfer to …

emergency medicinepsychiatrysystemdelaykalma
TASmental health2023-03-07

Coroner's Finding: Culic, Jana

35y · Female·neck and chest injuries and drowning due to intentional fall/jump from Tasman Br…

Jana Culic, aged 35, died by suicide jumping from the Tasman Bridge on 4 June 2020 while subject to a Mental Health Act treatment order for sc…

psychiatryemergency medicinemethamphetamine
SA2007-04-26

Coroner's Finding: CHRISTOPHER Penelope Rae and TRENORDEN John

53y · Male·asphyxia from combined effects of neck compression from hanging and suffocation …

John Trenorden died by suicide in prison following his arrest for allegedly murdering his former business partner Penelope Christopher. …

psychiatrygeneral practicecommunicationsystemallopurinol

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