Coronial

746 results for psychiatric treatment

WA2022-07-15

Inquest into the Death of Sarwan Hekmat Salman AL JHELIE

21y · Male·complications of ligature compression of the neck (hanging)

… family and established supports; failure to initiate appropriate follow-up despite prior overdoses and psychiatric vulnerability; failure to obtain a court-ordered psychiatric assessment in timely fashion; and inadequa…

psychiatryaddiction medicinecommunicationsystemmethamphetamine
VICcommunity2010-06-09

Finding into death of Mark Bailey

26y · Male·Gunshot injury to the head (self-inflicted)

…y, alcohol dependence, and a history of violence, died from a self-inflicted gunshot wound. He was under treatment by a psychiatrist and psychologist who were not fully informed of his violent propensity and history. Hi…

psychiatrypsychologydiagnosticcommunicationparoxetine
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

…oluntary status following a Mental Health Review Board (MHRB) hearing. She was discharged on a Community Treatment Order (CTO) supervised by the Alma Street Centre. Key clinical lessons include: (1) the difficulty of de…

psychiatryintensive caresystemdelaypentobarbital
SAhospital2018-11-05

Coroner's Finding: SIZE Mervyn Eric

77y · Male·multi-organ failure due to general inanition on a background of end-stage Alzhei…

…'s dementia, died from multi-organ failure due to general inanition while subject to a Level 2 Inpatient Treatment Order at Repatriation General Hospital. His cognitive and physical decline was rapid following admission…

geriatric medicinepsychiatryoxazepam
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

…lf-harm and suicidal thoughts to family members but not consistently to clinicians. He was referred for psychiatric review but did not attend. The coroner found MDAS provided appropriate treatment but identified prevent…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
VICmental health2025-11-11

Finding into death of Graziano Birgi

86y · Male·Oesophageal perforation

An 86-year-old man with treatment-resistant paranoid schizophrenia residing in a secure psychiatric unit died from oesophageal perforation…

psychiatrygeriatric medicine
SAhospital2020-05-08

Coroner's Finding: HALL Bryan Robert

71y · Male·general inanition on a background of end-stage mixed pattern dementia and acute …

… inanition secondary to end-stage mixed dementia and acute renal failure while under a Level 2 Inpatient Treatment Order at Repatriation General Hospital. He had a complex medical history including Alzheimer's and vascu…

geriatric medicinepsychiatry
QLDcommunity2015-12-14

Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra

42y · Male·Anthony Young: multiple gunshot wounds to the body and arm; David Young: multipl…

… partner Louise. Anthony had deteriorating mental health including paranoia, substance use, and lack of psychiatric engagement despite family attempts to obtain help. Police responded appropriately within 9 seconds to a…

psychiatryforensic medicinediazepam
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

…rt, no consular assistance, and severe depression with anxiety. Top End Health Service provided minimal psychiatric care with brief consultations (3-31 minutes), insufficient history-taking, conflicting assessments of h…

general practicepsychiatrydiagnosticcommunicationsertraline
VIC2008-01-25

Finding into death of Lee Andrew Kennedy

40y · Male·Haemorrhage from gunshot wound to chest

Lee Andrew Kennedy, a 40-year-old man with a history of mood instability, migraines, and medical treatment through a GP and psychiatrist, died from a gunshot wound to the chest inflicted by Constable Erin Levay …

general practicepsychiatrysystemlithium
VICcommunity2014-12-22

Finding into death of Dean Alan Carlson Laycock

24y · Male·Strangulation by hanging

…stmas Eve 2009, four hours after being informed that his anticipated 4-day Christmas leave from PARC (a psychiatric step-down facility) would be reduced to 2 days. The clinical team made this decision without consulting…

psychiatrypsychologycommunicationsystemclozapine
WAhospital2005-03

Inquest into the Death of Bert Sharpe

58y · Male·Gastrointestinal haemorrhage due to erosive gastritis

… due to erosive gastritis at Sir Charles Gairdner Hospital on 19 April 2004. He had been an involuntary psychiatric patient at Graylands Hospital since 1992, following a severe head injury sustained in a motor vehicle a…

psychiatrygeneral surgery
SAhospital2006-12-14

Coroner's Finding: PETTER Elemer

79y · Male·myocardial infarction

…all identified extensive acute MI. Given his age, comorbidities, poor prognosis, and refusal of invasive treatment, a palliative approach was agreed with his close friend. The coroner found treatment was of extremely hi…

cardiologypsychiatrycommunicationhaloperidol
SAhospital2020-06-17

Coroner's Finding: TIERNAN John Joseph

78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect

… a large left basal ganglia intracerebral haemorrhage with mass effect while admitted under an Inpatient Treatment Order (ITO) for acute hyperactive delirium. He had stage 4 lung cancer with extensive brain metastases d…

psychiatryneurology
QLDmental health2007-03-02

Lather, David Andrew

24y · Male·aspiration of gastric contents due to or as a consequence of drug toxicity follo…

…after ingesting approximately 150 tablets from a medication drawer beside his bed. Andrew had a complex psychiatric history including schizophrenia, multiple suicide attempts, self-harm, and a severe overdose attempt in…

psychiatryrehabilitation medicinesystemcommunicationquetiapine
WAmental health2001-02-02

Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

… long-acting injection, leading to suspected neuroleptic toxicity. Care was transferred to an intensive psychiatric acute care unit with enhanced nursing supervision. After withdrawal of anti-psychotic medications and t…

psychiatryintensive caremedicationflupenthixol decanoate
VICcommunity2018-02-23

Finding into death of Kenneth James Stephens

51y · Male·unascertained; presumed sudden cardiac arrhythmia

…51-year-old man with schizoaffective disorder, died from an unascertained cause while under involuntary psychiatric care. He presented with acute behavioural changes including excessive drinking, unusual fluid/milk cons…

psychiatryemergency medicinepaliperidone
NSWhome2016-09-30

Inquest into the death of Terry Riordan

45y · Male·multi-drug toxicity from ingestion of methadone and amitriptyline

…drug toxicity caused by ingesting amitriptyline and methadone in April 2015. He had complex medical and psychiatric comorbidities, substance abuse issues, and was under care of his GP Dr H. for 17 years. Critical clinic…

general practicepsychiatrymedicationdiagnosticmethadone
NSWcommunity2017-10-25

Inquest into the death of KE

36y · Male·Shotgun wound to the head

KE was a 36-year-old with longstanding psychiatric history including borderline personality disorder, substance abuse, and multiple previous self-harm inc…

psychiatryemergency medicinealcohol
NSWcommunity2026-05-19

Inquest into the death of Dion White-Cotterell

45y · Male·Multiple stab wounds

…ing acute schizophrenia relapse with a long history of violence and substance abuse, was under Community Treatment Order supervision through Parramatta Community Mental Health Centre. The inquest found systemic failures…

psychiatrysystemcommunication
121222338

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