Coronial

746 results for psychiatric treatment

VICcommunity2021-11-25

Finding into death of Daniel Neil Thomas

35y · Male·Gunshot wound to the head (self-inflicted)

…ound during a police siege. He had a history of substance-induced psychosis from ice use, with multiple psychiatric admissions in 2015-2016. Following discharge, he declined mental health follow-up and community treatme…

psychiatryemergency medicinesystemcommunicationmethamphetamine
VICcommunity2015-05-29

Finding into death of Craig Doherty

49y · Male·Multiple injuries from a fall from height

…e with Olanzapine. Despite being assessed as requiring either hospital admission or supervised community treatment, he chose community-based medication supervision. He was assessed as denying suicidal ideation and appea…

psychiatrygeneral practicelithium
VICcommunity2018-09-18

Finding into death of Gerald Vanderwerf

56y · Male·unascertained; presumed suicide by unknown means

…ospectively after resolution; treating psychiatrist never saw him in crisis; he repeatedly withdrew from treatment; he minimised symptoms due to shame about unemployment and psychiatric history; and he declined multiple…

psychiatrygeneral practicecommunicationsystemlamotrigine
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

…ho relied on incomplete verbal handovers rather than reading clinical records; (4) transfer from secure psychiatric intensive care to an open ward without intensive supervision was inappropriate for her clinical acuity;…

psychiatryemergency medicinediagnosticmedicationvecuronium
SAmental health2022-07-08

Coroner's Finding: Cardwell, Phillip David

53y · Male·lung abscess with empyema

A 53-year-old man with schizophrenia died from lung abscess with empyema while an involuntary inpatient at a mental health facility. He had been readmitted with a respiratory infection and was treated with intravenous an…

psychiatryemergency medicinedelayclozapine
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suici…

psychiatryemergency medicinesystemdelaymirtazapine
WAmental health2015-11-30

Inquest into the Death of Frances May COOPER

48y · Female·Head injury

… a Department of Health smoking prohibition policy forcing patients to leave the ward, and insufficient psychiatric continuity. The decision to allow unescorted leave was ultimately mistaken but not inherently wrong at …

psychiatryemergency medicineproceduralsystemrisperidone
VIChospital2010-05-03

Finding into death of Christian Gonzalo Diaz

28y · Male·hypoxic brain injury presumed to have occurred as a direct result from toxicity …

…d from hypoxic brain injury following presumed heroin toxicity on 9 January 2008. He was an involuntary psychiatric inpatient with schizophrenia and substance abuse history when he absconded from escorted leave on 5 Jan…

psychiatryintensive careheroin
NSW2025-03-06

Inquest into the death of Muhammad Hafizuddin Bin Zaini

29y · Male·hanging

…ental health care was adequate and whether communication regarding repatriation was appropriate. Expert psychiatric evidence confirmed his mental health monitoring and treatment were adequate. He received multiple menta…

psychiatrygeneral practicecommunicationolanzapine
VIChome2012-08-23

Finding into death of Shane Anthony Jarrett

29y · Male·Mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) in a morbidly …

…mixed drug toxicity (heroin, clozapine, zuclopenthixol, diazepam) complicated by morbid obesity. During psychiatric hospitalization, he gained 35kg in four months after clozapine recommencement, reaching BMI 49.87. Whil…

psychiatrygeneral practicesystemdelayheroin
ACTmental health2023-06-27

Inquest into the death of MERREN ELIZABETH BARTLEY

67y · Female·ischaemic heart disease

…at 3:40am after overnight two-hourly monitoring. The coroner found no evidence that the quality of care, treatment, or supervision at any facility contributed to her death. Death resulted from natural causes—advanced co…

psychiatrycardiologyclozapine
VICaged care2025-09-10

Finding into death of Frances Mary Hayden

78y · Female·Complications of mandibular fractures sustained in a fall, in the setting of mal…

… coroner found her care was reasonable and appropriate, and that she was given appropriate agency in her treatment decisions, including her refusal of investigations for gastrointestinal bleeding and further interventio…

geriatric medicinepsychiatry
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

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

…icide attempts, died by hanging in the Northern Psychiatry Unit on 24 June 2010 while under involuntary psychiatric admission. She had presented to emergency with acute suicidality on 18 June, attended police station in…

psychiatryemergency medicinecommunicationsystemquetiapine
VIChospital2011

Finding into death of PB

40y · Male·carbon monoxide poisoning

…d at Frankston Hospital ED on 16 August 2009 following police intervention at a suicide attempt. The ED psychiatric assessment rated his suicide risk as medium and discharged him home with minimal follow-up arrangements…

emergency medicinepsychiatrydiagnosticcommunication
NSWcommunity2017-06-09

Inquest into the disappearance and suspected death of Katherine ACKLING-BRYEN

37y · Female·open finding - undetermined

…al health follow-up with no ongoing therapy or strong therapeutic relationship established. She stopped psychiatric medication in 2015 during pregnancy and did not resume it after a subsequent miscarriage in November 20…

psychiatrygeneral practicesystemcommunicationanti-psychotic medication
WAcommunity

Inquest into the Death of Sarah Jane RUTHERFORD

28y · Female·multiple injuries

…e on 23 December with a seven-day prescription and expected discharge within days. The coroner found the treatment and care at Graylands was reasonable and appropriate. However, the case highlights risks of symptom mask…

psychiatryemergency medicinerisperidone
VIChospital2015-10-14

Finding into death of Marc Phillip Vella

39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor

…ealth deteriorated during admission, necessitating a Mental Health Act order variation to enable medical treatment. Despite appropriate clinical management and ICU admission, he died from infective endocarditis caused b…

emergency medicinegeneral medicinemethamphetamine
VIChome2014-10-06

Finding into death of Peter Andrew McNay

50y · Male·hanging

…il 2011, he increased substance use. On 1 July 2012, he called Mercy Mental Health Crisis Assessment and Treatment Team stating he wanted to hang himself and was actively attempting to tie a noose. The psychiatric nurse…

psychiatryaddiction medicinealcohol
QLD2013-09-24

Emerton, Andrew John Joseph

43y · Male·Coronary Atherosclerosis

Andrew Emerton, a 43-year-old prisoner with a history of substance abuse and psychiatric treatment, collapsed after vigorous exercise in custody. He called for help reporting shortness of brea…

cardiologyemergency medicinequetiapine
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic d…

psychiatryemergency medicinediagnosticcommunicationescitalopram
120212238

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