Coronial

746 results for psychiatric treatment

NSWhome2019-10-18

Inquest into the death of Aron MYERS

45y · Male·cardiac arrhythmia whilst being restrained, in the context of methamphetamine as…

…zophrenia, substance abuse, and aggressive behaviour should be aware of concurrent cardiac risks. Early psychiatric intervention and substance abuse treatment might have prevented the escalation. The coroner found restr…

psychiatrycardiologymethamphetamine
VICcommunity2021-03-10

Finding into death of Casey Evan Cahill

19y · Male·Multiple injuries sustained on a train impact (pedestrian)

…, cocaine, and alcohol. He was enrolled in the Headspace Youth Early Psychosis Program and was receiving treatment with antipsychotic medication (aripiprazole depot). Key clinical lessons include: the importance of earl…

psychiatryaddiction medicinesystemalcohol
TAScommunity2025-07-04

Coroner's Finding: de-identified KT

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

…ng to involuntary mental health orders. The coroner found he received appropriate medical assessment and treatment, including involuntary orders when necessary. However, he was non-compliant with medications, withdrew f…

psychiatryemergency medicinepaliperidone
NSWcommunity2023-12-14

Inquest into the disappearance and suspected death of XA

36y · Male·Unascertained

A 36-year-old male psychiatrist disappeared on 25 January 2023 and is presumed deceased. He had treatment-resistant depression, was in significant pain from a recent back injury, and was prescribed opioids (Lyr…

psychiatrygeneral practicepregabalin
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

… clinical care decisions were appropriate, the larger system failed to provide adequate alternatives to psychiatric hospitalisation for her complex needs.

psychiatrygeneral medicinesystemdelaylithium
TAShospital2025-04-11

Coroner's Finding: Decision in relation to Martin 'Marjorie' Harwood

38y · Female·end stage renal failure (Stage 5 chronic kidney disease)

…cal about undertaking dialysis due to her difficulty maintaining strict regimens amid substance use and psychiatric illness. Declining life-saving treatment for a terminal natural disease does not constitute suicide. Th…

nephrologygeneral medicine
TAShospital2024-11-26

Coroner's Finding: de-identified FG

57y · Male·partially suspended hanging

…lcohol-related brain injury) and personality features. Key clinical lessons: (1) Prolonged stays on non-psychiatric wards for patients with high suicide risk require enhanced environmental safety measures including regu…

orthopaedic surgerypsychiatrycommunicationsystemdiazepam
VICmental health2023-06-22

Finding into death of Catherine Ann Williamson

58y · Female·plastic bag asphyxia

Catherine Williamson, a 58-year-old voluntary psychiatric inpatient, died from plastic bag asphyxia at a private mental health facility. She had schizo-affective…

psychiatrysystemcommunication
WAhospital2025-07-22

Inquest into the Death of Samaan Salah Tilmiz ELSAMIN

21y · Male·unascertained

Samaan Salah Tilmiz Elsamin, a 21-year-old with treatment-resistant schizophrenia, moderate-to-severe intellectual disability (IQ 57), and unpredictable violent b…

psychiatryintensive caresystemdelayclozapine
VICmental health2017-05-18

Finding into death of Derek Hamilton

46y · Male·Cerebral ischaemia secondary to compression of the neck in circumstances of hang…

Derek Hamilton, a 46-year-old involuntary psychiatric patient with cluster B personality disorder and recurrent depression, died from cerebral ischaemia seco…

psychiatryintensive caresystemcommunicationmirtazapine
VIC2021-05-07

Finding into death of Joanne Finch

42y · Female·Neck compression due to self-suspension

…Centre on 24 July 2018. She had chronic suicidal ideation with periods of acute risk, was under regular psychiatric review, and was managed with appropriate risk ratings (S2 at time of death). The coroner found that men…

psychiatrypsychologyolanzapine
SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

…erstanding the obligation to breach confidentiality and contact family when a minor presents with acute psychiatric symptoms; and establishing clear referral pathways to emergency mental health services (ACIS). The case…

psychologypsychiatrydiagnosticcommunication
WAmental health2024-08-28

Inquest into the Death of Peter Jonathon Rex BOLTON

36y · Male·ligature compression of the neck (hanging)

…, he created a ligature from a bed sheet using the ensuite bathroom door. The coroner found supervision, treatment and care were of high standard and appropriate. Key lessons: suicide is unpredictable and rare events ca…

psychiatryemergency medicinehaloperidol
TAShospital2023-05-31

Coroner's Finding: Richardson Rebecca Eileen

29y · Female·acute myocardial infarction due to stenotic coronary vessel (left anterior desce…

…ing, initially attributed to cannabis use. Her behaviour was disruptive; she refused full assessment and treatment. The coroner found her management at NWRH was reasonable given available guidelines. However, a more det…

emergency medicinecardiologydiagnosticcommunicationinsulin
VICmental health2022-12-15

Finding into death of Christopher Traill

55y · Male·Hanging

Christopher Traill, a 55-year-old lawyer with alcohol dependence and depression, died by hanging in a psychiatric inpatient unit on 25 February 2017, just hours after admission as a compulsory patient. He used his bel…

psychiatryproceduralcommunicationdiazepam
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

…aged from community mental health services despite outreach attempts. The patient had capacity to refuse treatment and couldn't be involuntarily detained without acute crisis. Earlier recognition of disengagement, proac…

psychiatrygeneral practicesystemdelaypaliperidone
SAhospital2004-05-19

Coroner's Finding: WOZNIAKOWSKI Andrzej

83y · Male·inanition with lobar pneumonia

…received comprehensive multidisciplinary care including medical, nursing, dietary, speech pathology and psychiatric input. Despite these efforts, his condition deteriorated rapidly due to advanced cachexia and he develo…

emergency medicinepsychiatry
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

…rist oversight after June 2007 (reviewed by multiple registrars); Jennifer's repeated non-attendance at psychiatric appointments without adequate follow-up; communication gaps between services; and absence of faxed hand…

psychiatrygeneral practicecommunicationsystemstillnox
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

…ural and mental health crises from adolescence. Despite multiple emergency department presentations and psychiatric admissions, he was repeatedly discharged with inadequate community follow-up. A critical gap existed in…

psychiatryemergency medicinediagnosticcommunicationcitalopram
VIChome2024-01-11

Finding into death of Madeline Jane Howe

20y · Female·Complications of neck compression in the setting of partial suspension

…EBMHS) with documented suicidal ideation, previous attempts via overdose and other means, and a complex psychiatric history. While NEBMHS provided appropriate initial assessment and safety planning, continuity of care w…

psychiatryemergency medicinecommunicationsystemfluoxetine
122232438

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.