Coronial

92 results for acute suicidal behaviour

VIChospital2017-07-28

Finding into death of Nicole Susan Evans

33y · Female·blunt impact injuries to neck and chest

…p by community mental health services (CLEARS). However, the second ED presentation on 28 October revealed acute self-harm and escalating suicidal ideation. The assessing clinician failed to review available clinical do…

psychiatryemergency medicinediagnosticcommunicationsertraline
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health…

psychiatrypsychologysystemproceduralpentobarbitone
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

…ould have prompted intervention to prevent this tragedy. The case highlights the challenges in identifying acute suicide risk in distressed individuals and the importance of comprehensive family support during terminal …

paediatricspsychiatrycommunicationsystemmirtazapine
VIChome2022-08-31

Finding into death of B L

28y · Male·neck compression consequent upon hanging

A 28-year-old man with severe personality disorder, substance use history, and recent suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide thr…

psychiatryemergency medicinecommunicationsystemsodium valproate
VIChome2020-01-14

Finding into death of A S

46y · Female·Combined drug toxicity in a woman found in a bath

…type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was under care of multiple mental health services. Critical clinical lessons include: (1) imp…

psychiatrygeneral practicecommunicationsystemphentermine
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

…ng using a bed sheet attached to exposed window bars in the toilet. Critical failures included: housing an acutely suicidal patient in an area with accessible hanging points despite prior staff warnings about this risk;…

psychiatrycorrectional healthcommunicationsystemcarbamazepine
VICcommunity2012-12-10

Finding into death of Benjamin Jason Pappas

28y · Male·consistent with drowning

…Pappas, a 28-year-old with a history of substance abuse, depression, borderline personality disorder, and suicidal ideation, died by drowning on approximately 4 March 2007, following the discovery that his partner Lynett…

general practicepsychiatrysystemcommunicationheroin
QLDhome2022-01-18

Lewis, Daniel Patrick

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

…eteriorating mental health despite recent psychiatric intervention, substance abuse triggers for violent behaviour, and the challenge of managing acute crises in patients with brain injury and polysubstance use.

psychiatryemergency medicinecommunicationsystemalcohol
VIChospital2012-12-13

Finding into death of William Andrew Poskitt

31y · Male·Injuries sustained in a fall from height

… and displaying clear signs of psychological distress (racing thoughts, insomnia, dark thoughts, bizarre behaviour, anxiety), he did not receive a formal mental state assessment. The treating team referred him to HIV Ps…

infectious diseasespsychiatrycommunicationdiagnostictrimethoprim
VIC2022-04-04

Finding into death of Naser Vukovic

42y · Male·Incised injury to the neck resulting in exsanguination and air embolism

…wo prior self-harm incidents with razor blades in April and May 2016, and clinical assessment recommending acute assessment unit admission, he remained on a waiting list and was housed in a mainstream unit with unrestri…

psychiatrycorrectional healthsystemdelayquetiapine
VIChome2014-11-28

Finding into death of Chanelle Amy Rae

14y · Female·Compression of the neck in circumstances of hanging

Chanelle Rae was a 14-year-old girl who died by hanging at home following an argument with a school friend online. She had no prior mental health history or significant stressors. The coroner identified a youth suicide c…

psychiatrypublic healthsystemdelay
VIC2022-07-15

Finding into death of Noel Thomas

42y · Male·hanging

… de-escalation of observation status in high-risk prisoners, despite explicit statements about concealing suicidal intent, may be unsafe; (4) frequent prison transfers disrupted continuity of mental health care; (5) inte…

psychiatrycorrectional healthsystemcommunication
NSWcommunity2024-06-18

Inquest into the death of Samuel Segal

27y · Male·The available evidence does not allow for any finding to be made as to the cause…

…lise his situation. He was experienced in bushwalking and rock climbing. The coroner noted no evidence of suicidal intent prior to disappearance, though acknowledged the possibility of either suicide or fatal misadventur…

general practicepsychologymethamphetamine
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

… of mental illness, personality disorder, and poly-drug abuse. On the morning of her death, she expressed suicidal ideation to multiple staff members, but no one initiated the At Risk Management System (ARMS), a protocol…

psychiatrygeneral practicecommunicationsystemzuclopenthixol
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

…ing marital and financial crisis, also accessed firearms readily despite an instructor noting concerning behaviour. The coroner identified that neither individual held firearms licenses or club memberships, making them …

psychiatryemergency medicinesystemcommunication
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

… at supported accommodation in April 2006. He had Aspergers Syndrome diagnosed at age 4, with escalating behavioural and mental health crises from adolescence. Despite multiple emergency department presentations and psy…

psychiatryemergency medicinediagnosticcommunicationcitalopram
VIChome2024-08-28

Finding into death of Ryley Ann Cox

Unknown·Sodium nitrite toxicity

…ion, anxiety, chronic pain, and medical conditions including emphysema and legal blindness, and expressed suicidal ideation approximately one year before death. Ryley had depression, substance abuse history, and became i…

psychiatrypsychologysodium nitrite
TAShome2013-08-09

Coroner's Finding: Miss N de-identified

20y · Female·injury caused by hanging

A 20-year-old woman with a long history of eating disorder, obsessive-compulsive behaviours, and adjustment difficulties died by suicide in October 2009. She had received treatment at the Bronte …

psychiatrypsychologysystemdelaymethylphenidate
VICmental health2015-05-29

Finding into death of Majang Ngor

23y · Male·Hanging

… a disabled bathroom on 24 June 2013. He was admitted under the Mental Health Act following assessment for acute psychosis and had spent 39 days in seclusion across April and May. A key contributing factor was access to…

psychiatryemergency medicinesystemcommunicationamisulpride
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…

psychiatrygeneral practicediagnosticsystemmethylphenidate

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