Coronial

85 results for acute psychiatric episode

NSW2024-08-22

Inquest into the death of Russell Zaska

33y · Male·hanging

…and and Reception Centre on 23 September 2020. He had been remanded in custody for three weeks. Despite psychiatric assessment on 15 September identifying psychotic symptoms and thought disorder, he was commenced on ant…

psychiatrycorrectional healthsystemdelayolanzapine
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

…equired, relying solely on poor-quality video monitoring while he was in a padded cell. A more thorough psychiatric assessment considering his full history would likely have resulted in extended hospital treatment, prev…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
VICmental health2015-02-26

Finding into death of Paul Bernard Finck

47y · Male·pulmonary thromboembolism and deep vein thrombosis

Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted…

psychiatryemergency medicinearipiprazole
SAcommunity2002-06-19

Coroner's Finding: HEATLEY Alan Forsyth

17y · Male·cranial and facial trauma

A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic …

psychologypsychiatrydiagnosticcommunication
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that d…

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
TAScommunity2022-10-24

Coroner's Finding: Woldemichael, Nazrawi

19y · Male·unable to be determined

…ed suicidal statements specifically about the bridge, history of suicide attempts, and severe untreated psychiatric illness, this could not be proven without a body. A homicide allegation based on uncorroborated confess…

psychiatrytrauma surgerycommunicationsystemcannabis
VIChospital2017-06-07

Finding into death of Samer Rony Damouni

21y · Male·Compression of the neck consequent upon hanging

…aggressive behaviour; inadequate communication between emergency and mental health teams; and insufficient acute psychiatric beds leading to prolonged ED stay. The coroner recommended implementing a dedicated behavioura…

psychiatryemergency medicinecommunicationsystemmethamphetamine
VICmental health

Finding into death of GM

52y · Male·Unascertained

…utside despite guideline recommendations that newly admitted patients should not be granted leave until psychiatric assessment. After displaying elevated mood with 'grand plans' to drive to Cairns, he was appropriately …

psychiatryemergency medicinesystemcommunicationpholcodine
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

24y · Male·complications of ligature compression of the neck (hanging)

Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involu…

psychiatryneurologyescitalopram
TAScommunity2021-01-25

Coroner's Finding: Townsend, David Lester

69y · Male·Partial contact range gunshot wound of the head

…hronic suicidal ideation, died by gunshot wound to the head on 25 September 2017. He had been receiving psychiatric care from Dr McDougall and case management from community mental health services. Following a July 2017…

psychiatrygeneral practice
SAmental health2016-11-17

Coroner's Finding: ALCOCK, Ross Matthew

22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…

A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observ…

psychiatryintensive caresystemcommunicationolanzapine
SAhome2014-01-31

Coroner's Finding: HADLEY Duke Zenon

2y · Male·Asphyxiation due to neck and/or chest compression

… 2-year-old boy died from asphyxiation due to chest and neck compression inflicted by his mother during an acute manic psychotic episode. The mother had been admitted to psychiatric care in December 2008 with psychosis …

psychiatryemergency medicinecommunicationsystemrisperidone
VICmental health2014-11-17

Finding into death of Justin Peter Foster

40y · Male·unascertained

…man with bipolar affective disorder, chronic back pain, and substance abuse history, died suddenly in a psychiatric inpatient unit (Upton House) on 3 January 2012. He was admitted involuntarily on 30 December 2011 durin…

psychiatryforensic medicinecommunicationdiazepam
TAShome2021-12-03

Coroner's Finding: Summers, Damian

42y · Male·hanging, an action taken by himself with the intention of ending his life

A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural isl…

psychiatrygeneral practicecommunicationsystemolanzapine
VICmental health2025-07-14

Finding into death of Maxwell Bernard Howard

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

…nia in the setting of pulmonary 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, …

psychiatryemergency medicinecarbamazepine
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired…

psychiatryneurologydiagnosticcommunicationolanzapine
SAhospital2005-05-24

Coroner's Finding: WALLACE-MOHLMANN Candice Mackenzie

30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…

…um and atropine obtained from a hospital storeroom. She was admitted under Mental Health Act detention for acute psychosis. Critical clinical lessons include: (1) her antipsychotic medication was inadequate despite flor…

psychiatryemergency medicinediagnosticmedicationvecuronium
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

…included: inexperienced control room staff failing to recognise his escape alarm, lack of continuity of psychiatric care across facility transfers, absence of face-to-face psychiatric assessment at Christmas Island, and…

psychiatrygeneral practicesystemcommunicationmirtazapine
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…tressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania and psychosis, requiring compulsory psychiatric hospitalization. After three weeks inpatient treatme…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SAhospital2000-11-20

Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam

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