Coronial

746 results for psychiatric treatment

VICcommunity2019-06-13

Finding into death of Diane Bell

52y · Female·Plastic bag asphyxia and asphyxia in the setting of an irrespirable environment

…halation in June 2017. She had been under care of North West Area Mental Health Service with a Community Treatment Order and was receiving multidisciplinary support including psychiatry and psychology. Despite ongoing s…

psychiatrypsychologyolanzapine
VIC2014-10-15

Finding into death of Benjamin Elijah Mills

31y · Male·Hanging

…iving psychological support, died by hanging in his cell at Barwon Prison. Despite ongoing mental health treatment and plans for transfer to a safer unit, he was able to fashion a ligature from prison materials (a boxin…

psychiatrypsychologysystemdelay
SA2022-03-30

Coroner's Finding: Papadopoulos, George

63y · Male·disseminated carcinoma (pancreatic cancer with metastases to liver and lung)

…uccessful kidney cancer surgery in Serbia, significantly impeded engagement with the healthcare system. Psychiatric assessment confirmed he was competent to refuse treatment. The coroner concluded no deficit in standard…

general practicecorrectional health
SAhospital2007-07-02

Coroner's Finding: VINER Robert John

58y · Male·Hypoxic encephalopathy secondary to cardiac arrest due to cardiomegaly

… severe hypoxic encephalopathy and was extubated on 30 July 2006, dying at 6:40pm. The coroner found his treatment appropriate with no suspicious circumstances. The underlying cardiac pathology (cardiomegaly) appears to…

psychiatryemergency medicineolanzapine
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

… suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asphyxiation as a contemplated suicide method. Following he…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…

… emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbidities including congestive heart failure, COPD, and bipolar disorder, wit…

psychiatryemergency medicinecarbamazepine
NSWcommunity2018-07-27

Inquest into the disappearance and suspected death of Kellie Anne Levitski

38y · Female·Unable to be determined

Kellie Anne Levitski disappeared on 31 March 2014 from her father's property near Bega, NSW. She had schizoaffective disorder requiring intensive mental health support, depot antipsychotic injections, and multiple medica…

psychiatrysystemdelay
TAShome2018-08-31

Coroner's Finding: Green, Paul William

66y · Male·carbon monoxide poisoning due to inhalation of exhaust gases from a lawn mower

…up but received inadequate ongoing support. Key clinical lessons include: (1) older males with multiple psychiatric comorbidities, physical health issues, social isolation, and substance abuse require intensive, coordin…

psychiatrygeneral practicecommunicationsystemantidepressant medication
VIChome2022-09-07

Finding into death of Kim Rebecca Lynch

41y · Female·neck compression

…vised leave despite high-risk status; he absconded and met with Lynch. The AWOL procedure had gaps: the Psychiatric Triage Service wasn't notified, nominated contacts weren't contacted within 30 minutes, and the missing…

psychiatryemergency medicinecommunicationsystemmethadone
VICmental health2017-04-07

Finding into death of Natasha Calleja

32y · Female·combined drug toxicity, mainly heroin

…old, died from combined drug toxicity (mainly heroin) while an involuntary inpatient at Swanston Centre psychiatric unit after her de facto partner supplied heroin during an unsupervised visit. She had been admitted fol…

psychiatryemergency medicinecommunicationsystemheroin
VICcommunity2016-12-14

Finding into death of Jake James-Kotsanas

23y · Male·Haemorrhage from incised wounds to the neck and wrists

Jake James-Kotsanas, 23, died from haemorrhage from self-inflicted knife wounds to his neck and wrists while experiencing a drug-induced psychotic episode following acute methylamphetamine intoxication. He had a complex …

psychiatrytoxicologymethamphetamine
QLDcommunity2009-06-19

Hatch, Clay

34y · Male·gunshot wound to the neck

…nding Hatch in the neck. The coroner found the officer's use of force was justified. While mental health treatment was appropriate and supported by his family, the incident highlights challenges managing severe psychosi…

psychiatryemergency medicinecommunicationsystemamphetamine
TAScommunity2022-12-15

Coroner's Finding: Wildman, Benjamen

37y · Male·self-inflicted stab wound to the chest

…provided was appropriate; his psychiatrist concluded personality disorders of this severity have limited treatment efficacy, particularly in rural settings. Wildman had recently breached a family violence order protecti…

psychiatrypsychology
QLD2008-03-17

Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael

gunshot wounds; multiple deaths during police interventions with mentally ill in…

…cially for released prisoners), and insufficient integration of alcohol/drug services with mental health treatment. The coroner made 17 recommendations focused on standardised mental health assessments, revised involunt…

psychiatryemergency medicinediagnosticcommunicationantipsychotic medications
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

24y · Male·cardio-respiratory arrest due to multi-drug toxicity

… severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death resulted from cardio-respiratory ar…

psychiatryemergency medicinecommunicationsystemdiazepam
WAmental health2013

Inquest into the Death of Vos, Glenis June

60y · Female·Focal pneumonia in a woman with emphysema and ischaemic heart disease

… died several hours earlier. The coroner found the death arose from natural causes and that supervision, treatment, and care were adequate. Clinical lessons include the challenge of managing medically complex patients w…

psychiatrygeneral medicinetemazepam
VICcommunity2012-11-30

Finding into death of Simon Kirwan

19y · Male·Ruptured aorta post motor vehicle incident

Simon Kirwan, 19, died by motor vehicle collision in circumstances indicating suicide after discharge from involuntary mental health care. He had made three serious suicide attempts within 7 days (overdoses, wrist lacera…

psychiatryemergency medicinediagnosticcommunicationdiazepam
TAShome2022-07-21

Coroner's Finding: Moran, Kayla Maree

31y · Female·hanging

…e been foreseen or prevented given her private nature and concealment of difficulties, despite receiving treatment and support offers.

general practicepsychiatrydiagnosticcommunication
WAmental health2005-06-30

Inquest into the Death of Jessica Mary Dewhurst

20y · Female·Ligature compression of the neck

… The coroner found her death was by suicide, likely impulsive rather than planned, and that supervision, treatment and care were adequate given the inherent tension between safe and therapeutic environments in mental he…

psychiatrygeneral medicinefluoxetine
VIChome2025-10-16

Finding into death of Ms YPM

27y · Female·Hanging

… coroner found no evidence that clinicians erred in determining she did not meet criteria for compulsory treatment under mental health legislation, deficiencies were identified in communication and discharge planning. K…

psychiatryemergency medicinecommunicationdelayagomelatine
128293038

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