Coronial

746 results for psychiatric treatment

QLDhome2022-01-18

Lewis, Daniel Patrick

36y · Male·Gunshot wounds to the chest and abdomen

…e not outcome-changing. Key clinical lessons: recognition of deteriorating mental health despite recent psychiatric intervention, substance abuse triggers for violent behaviour, and the challenge of managing acute crise…

psychiatryemergency medicinecommunicationsystemalcohol
SAhospital2016-10-10

Coroner's Finding: MACMILLAN Kay Meredith

62y · Female·end-stage heart failure due to cardiac amyloidosis

…yloidosis died from cardiogenic shock approximately 90 minutes after being placed on a Level 1 inpatient treatment order. She had wished to discontinue treatment, reflecting her terminal condition and in alignment with …

cardiologypsychiatrydiagnosticcommunicationmirtazapine
QLDhospital2005-10-06

Fernandez, Adam Anthony

33y · Male·Aspiration due to alcoholic intoxication; coronary atherosclerosis contributed

…ful. The coroner found no clinical failures: police intervention was lawful and appropriate, and medical treatment—including sedation and emergency airway procedures—was correct and expert-reviewed. Aspiration in the co…

emergency medicineanaesthesiasedatives
VIChome2023-06-06

Finding into death of Michael Stephen Delaney

37y · Male·Plastic bag asphyxia

Michael Delaney, a 37-year-old man with treatment-resistant schizophrenia, died by plastic bag asphyxia while residing at supported independent living acc…

psychiatrycommunicationsystemdiazepam
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

…eep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensation and received sedation (haloperidol and clonazepam) for agitation. He was observed hourly…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
SAhospital2021-11-23

Coroner's Finding: Barry, Margaret Joan

80y · Female·Right haemothorax due to bleeding right pleural adhesion with contributing apixa…

…ixaban anticoagulation therapy for atrial fibrillation. She was admitted to Royal Adelaide Hospital for psychiatric care under an Inpatient Treatment Order for mania following cessation of carbamazepine. On 24 April 201…

psychiatrycardiologyapixaban
QLDcommunity2025-05-02

Non-inquest findings into the death of Mr T.

49y · Male·undetermined

…tigations, and ensuring mental health and police communication barriers are minimised during involuntary treatment escalations.

psychiatrysystemcommunicationclozapine
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

…al admission would have been prudent given the persistent suicidal ideation, continuing symptoms despite treatment, and the partner's expressed concerns. The coroner found the approach was within broad clinical standard…

psychiatrygeneral practicediagnosticcommunicationsertraline
VICmental health2014-12-05

Finding into death of Wieslaw Albin Bernacki

62y · Male·hanging

…th a long history of severe schizophrenia died by hanging after being granted escorted day leave from a psychiatric inpatient unit. The coroner identified critical failures in communication between hospital staff and th…

psychiatrycommunicationsystemantipsychotics
VICaged care2026-01-19

Finding into death of Kevin Thomas Maloney

39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…

… require appropriate training and clear protocols; (3) support plans must be updated promptly following psychiatric hospitalization or relapse; (4) effective handovers between shifts are critical safety measures; (5) me…

psychiatryaddiction medicinecommunicationsystemheroin
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

…conded from his supported residential service and was found deceased. The coroner found Austin Health's psychiatric assessment and management suboptimal, highlighting failures to: utilise relapse prevention plans, antic…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
VIChospital2014-01-29

Finding into death of Renee Andrea Treen

24y · Female·multiple injuries from jumping off Bulla Road overpass onto Tullamarine Freeway

Renee Treen, aged 24, died by suicide from the Bulla Road overpass while an involuntary psychiatric patient. Critical failures included: inadequate assessment of suicide risk (prior freeway-adjacent beha…

psychiatrydiagnosticsystemrisperidone
VICcommunity2012-08-17

Finding into death of Jesse Ross Sangster

28y · Male·Multiple injuries sustained in a motor vehicle collision (driver)

…riday 29 January without case manager involvement or family notification; and failure to arrange urgent psychiatric review until 4 February, which never occurred. Post-discharge observations on 2 February showed clear r…

psychiatryparamedicinesystemdelayalcohol
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

…medicated and unassessed by psychiatry, and was left alone when his cellmate was transferred for medical treatment. The coroner found that placement in a two-person cell until psychiatric assessment, prompt medication r…

psychiatrygeneral practicediagnosticcommunicationescitalopram
NSWmental health2014-08-08

Inquest into the death of Josephine LAMBERT

44y · Female·natural causes, possibly a cardiac arrhythmia

Josephine Lambert, 44-year-old woman with treatment-resistant schizophrenia, died at Cumberland Hospital on 28 July 2011. She was found unconscious in the h…

psychiatryforensic medicineclozapine
VIC2014-09-11

Finding into death of Lloyd Felman

58y · Male·Amitriptyline toxicity

…involuntary admission criteria under Mental Health Act, as he denied suicidal ideation, showed no acute psychiatric symptoms, and lacked clear mental illness. Clinicians appropriately applied the legal criteria for invo…

psychiatryemergency medicineamitriptyline
WAcommunity2005-11-04

Inquest into the Death of Sheridan Troy Hilton

42y · Female·Ligature compression of the neck (hanging)

…rioration, she was admitted to Busselton District Hospital on 18 August 2003 and transferred to Bentley Psychiatric Hospital on 21 August. Although assessed as a voluntary patient with protective factors (family support…

general practicepsychiatrycommunicationsystemmirtazapine
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

Anna Lee, a 70-year-old retired psychiatric nurse, died from asphyxia due to airway obstruction while an inpatient in a mental health unit. She was…

psychiatrygeriatric medicinesystemolanzapine
VIChomePodcast2023-12-11

Finding into death of Shane Michael Tuck

38y · Male·hanging

…upport was deemed appropriate. The inquest noted that earlier recognition of neurocognitive decline and psychiatric symptoms in contact sport athletes with repetitive head trauma could enable earlier intervention and pr…

neurologypsychiatrycocaine
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

David Geoffrey Godley, aged 30, died from exsanguination due to self-inflicted multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression…

psychiatryemergency medicinedelaymethamphetamine
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