Coronial

746 results for psychiatric treatment

WAhospital2009-08-13

Inquest into the Death of Greeuw

45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction

…g of faeces). Recommendations addressed the need for timely physical examination of settled involuntary psychiatric patients, implementation of bowel charts for patients on constipating medications, and clarification of…

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
SAhome2019-07-24

Coroner's Finding: McNAMARA-CUTLER Juanita Lee

26y · Female·neck compression due to hanging

…empts, died by hanging on 7 September 2014, three days after release on home detention bail as part of a Treatment Intervention Court program for drug-related offences. She had a documented history of depression, PTSD, …

psychiatryforensic medicinemethamphetamine
VICcommunity2024-11-13

Finding into death of N A

59y · Male·compression of the neck secondary to hanging

A 59-year-old man with treatment-resistant depression, anxiety, and suicidal ideation died by hanging while on weekend leave from psychia…

psychiatrypsychologycommunicationsystemvenlafaxine
SAhospital2025-07-03

Coroner's Finding: Cheesman, Trevor Allan

70y · Male·complications arising from craniofacial resection and orbital exenteration for r…

A 70-year-old man died following complex craniofacial resection and orbital exenteration for right sinonasal adenocarcinoma. Multiple surgical complications occurred including carotid artery injury, cerebral infarction, …

neurosurgeryENT surgerysystemolanzapine
VIChome2022-08-11

Finding into death of Christopher David French Hunter

31y · Male·hanging

…rvision and follow-up with CATS. The discharge plan lacked proactive CATS referral despite Christopher's treatment resistance and untreated psychosis. Although parents contacted CATS twice (12 and 17 June), seeking guid…

psychiatrycommunicationsystemolanzapine
VIChospital2022-08-31

Finding into death of Cindy Jane Martin

40y · Female·Complications of WHO Class III Obesity

Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac com…

psychiatryrespiratory medicinesystemdelaysodium valproate
SAhospital2018-02-05

Coroner's Finding: SISSONS Anthony Vincent

38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…

Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three separate occasions (13-15 June 2012) with constipation, which w…

general practiceemergency medicinediagnosticzuclopenthixol
TAScommunity2022-04-29

Coroner's Finding: Mawer, Stephen Charles

45y · Male·Self-inflicted burns (80-90% full and partial thickness burns across body)

Stephen Mawer, a 45-year-old man with longstanding depression, anxiety and suicidal ideation, died from severe burns sustained when he deliberately set himself alight during a police siege at his home. He had recently be…

general practicepsychiatry
VICmental health2021-05-28

Finding into death of Christopher John Peter Dewhurst

27y · Male·Multiple injuries sustained after being struck by a train

Christopher Dewhurst, 27, died by suicide after being struck by a train while on ground leave from a psychiatric unit. He was a compulsory patient subject to a Temporary Treatment Order, admitted with suicidal ideati…

psychiatryemergency medicinecommunicationsystemdesvenlafaxine
NSWmental health2019-12-04

Inquest into the death of Mitchell FLOOD-SMITH

23y · Male·Multiple injuries sustained following collision with a train

A 23-year-old man with a history of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2…

psychiatryparamedicinecommunicationsystemrisperidone
SAhospital2007-08-02

Coroner's Finding: GILLAM Peter Roy

44y · Male·Sepsis and pulmonary thromboemboli complicating a ruptured cerebral artery aneur…

…usion. The patient's resolved headache by day 2 was misinterpreted as excluding SAH. Early diagnosis and treatment would have provided >80% survival chance. Critical failures included: failure to obtain imaging despite …

emergency medicinegeneral practicediagnosticcommunicationsalbutamol
VIC2011-09-01

Finding into death of Elijah Michael Shelley

28y · Male·heroin toxicity

…e attempt on 27 October 2008. Under the care of Consultant Psychiatrist Dr A., he received comprehensive treatment with a discharge plan involving progressively increasing periods of escorted and unescorted leave. By 6 …

psychiatryheroin
SAhospital2013-08-27

Coroner's Finding: BALNAVES Craig Henri

43y · Male·ischaemic small intestine due to incarceration of bowel in a mesenteric defect

Craig Henri Balnaves, a 43-year-old man with treatment-resistant schizophrenia detained at Glenside Hospital under mental health orders, died from ischaemic sm…

general surgerypsychiatryantacid
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

…attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and psychiatric care, achieving stability. Upon remand in custody in December 2019, Justice Health obtained limited med…

psychiatrygeneral practicecommunicationsystemsertraline
TAScommunity2022-02-22

Coroner's Finding: BL de-identified

47y · Male·Extensive burns sustained in a deliberately set fire

A 47-year-old male died from extensive burns sustained in a deliberately set house fire on 29 November 2020. He had experienced a relationship breakdown and severe depression with suicidal ideation. He presented to hospi…

psychiatryemergency medicine
VIC2012-11-16

Finding into death of Rebecca Lazarus

25y · Female·Stab wounds to the chest and abdomen

…-old woman with intellectual disability, was fatally stabbed by her partner Travis Cooke who had chronic treatment-resistant paranoid schizophrenia, was on a Community Treatment Order, and had a history of violence and …

psychiatryemergency medicinecommunicationsystemclozapine
VIChome2019-08-15

Finding into death of Jovan Kozarov

62y · Male·Incised wound to the neck

…rther exploration of family violence risk and impact, including engaging the parents more extensively in treatment planning and providing family psychoeducation, may have better supported the family's safety. The corone…

psychiatryforensic medicinecommunicationsystem
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He wa…

psychiatryaddiction medicinemedicationproceduralmethadone
QLDmental health2013-07-02

Saccu, Jonathan Clarence

20y · Male·Multiple injuries due to contact with a train

Jonathan Saccu, a 20-year-old with severe treatment-resistant schizophrenia, absconded from an open mental health unit and was fatally struck by a train app…

psychiatrydiagnosticcommunicationdiazepam
VIChome2024-08-28

Finding into death of Ryley Ann Cox

Unknown·Sodium nitrite toxicity

…, engaging isolated patients with mental health conditions, and recognising when chronic conditions and psychiatric comorbidity create acute suicide risk requiring active treatment and support.

psychiatrypsychologysodium nitrite
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