Coronial

63 results for childhood abuse

TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

Six young people aged 12-17 years died by suicide between 2010-2014 in Tasmania. All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified s…

psychiatrypaediatricssystemcommunicationlamotrigine
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

…ug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relationship breakdown. She presented to healthcare se…

general practicepsychiatrydiagnosticcommunicationmorphine
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a traum…

paediatricspsychiatrydiagnosticcommunicationcannabis
VICmental health2022-12-13

Finding into death of Jamie Andrew Kowalewsky

27y · Male·Global cerebral ischaemic injury in the setting of hanging

Jamie Kowalewsky, a 27-year-old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide attempt, was voluntarily admitted to a low dependency psychiatric…

psychiatryintensive carecommunicationlorazepam
WAhospital2016-02-05

Inquest into the Death of Pauline Margaret DODD

51y · Female·Ischaemic heart disease

…She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childhood rheumatic fever causing cardiac valve damage requiring prosthetic replacement. She presented with an inf…

psychiatrycardiologydiagnosticolanzapine
WA2019-05-22

Inquest into the 5 Deaths in Casuarina Prison who are Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM

Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…

…ncy communication between PCS and Prison Health Service staff; and insufficient risk monitoring. Adverse childhood events and personality disorders were not adequately factored into suicide risk assessments. The coroner…

psychiatrypsychologysystemcommunication
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

0y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
VICcommunity2015-05-07

Finding into death of Krisinda Carmen Smart

15y · Female·toxicity to heroin

Krisinda Carmen Smart, aged 15, died from heroin toxicity on 20 January 2008. She was a child in care of the Department of Human Services subject to a Custody to Secretary Order. In the days before her death, there were …

paediatricsemergency medicinediagnosticsystemheroin
WAprison2017-02-28

Inquest into the Death of Jayden Stafford BENNELL

20y · Male·ligature compression of the neck (hanging)

Jayden Stafford Bennell, a 20-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died by ligature compression of the neck (hanging) in a cleaning storeroom on 6 March 2013. He had a complex psychiatric h…

psychiatrycorrectional healthcommunicationsystemquetiapine
SA2003-03-20

Coroner's Finding: VARCOE Alexander Wayne Keith

24y · Male·hanging

…ous charges. He had a complex history including prior self-harm in 1995-96, alleged prison rape, substance abuse, and a troubled childhood, but appeared mentally stable in December 2000. Critical systemic failures inclu…

psychiatrygeneral practicesystemcommunication
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-immolate d…

emergency medicinepsychiatrycommunicationsystem
NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

A 49-year-old man with severe schizoaffective disorder died by hanging in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attem…

psychiatrycorrectional healthcommunicationsystemolanzapine
QLDcommunity2021-09-10

Lock, Karina May and Lock, Stephen Glenn - Non-inquest findings

49y · Female and male·Gunshot wound to head inflicted by spouse

… Lock to specialist domestic violence support services despite her explicit disclosure of intimate partner abuse; a general practitioner treating both victim and perpetrator concurrently without formal risk assessment o…

general practicepsychiatrydiagnosticcommunicationcannabis
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

15y · Male·ligature compression of the neck (hanging)

Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…

psychiatrypaediatricssystemdelay
VICmental health2024-04-26

Finding into death of Allison Leah Randall

37y · Female·Hanging

Allison Randall, a 37-year-old woman with a history of anxiety, depression, and childhood trauma, was admitted to the Northern Hospital psychiatric unit on 15 May 2020 following acute concerns a…

psychiatrysystemdiazepam
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine
NT2025

Inquest into the death of Kumanjayi Walker

19y · Male·gunshot wounds to chest and abdomen

…Aboriginal communities. Key clinical/public health lessons include: inadequate mental health and substance abuse services contributed to vulnerabilities; failures in early intervention for young people with developmenta…

public healthpsychiatrycommunicationsystem
WAhospital2016-03-24

Inquest into the Death of Jesse Richard DELLAR

17y · Male·ligature compression of the neck (hanging)

Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentionally overdosin…

psychiatrygeneral practicediagnosticsystematomoxetine
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol

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