Coronial

112 results for completed suicide

WAhospital2015-07-16

Inquest into the Death of James Anthony STANCZYK

31y · Male·ligature compression of the neck (hanging)

… man with depression, suicidal ideation, and recent HIV diagnosis presented to emergency department after suicide attempt (carbon monoxide inhalation and diazepam overdose). Despite psychiatrists identifying him as extr…

emergency medicinepsychiatrycommunicationsystemdiazepam
WAhospital2016-09-08

Inquest into the Death of Anandakumar SELLAKATHIRKGAMAN

38y · Male·hypoxic brain injury and organ failure following compression of the neck (hangin…

A 38-year-old Sri Lankan asylum seeker died by suicide after being released from immigration detention on a bridging visa. He had documented anxiety and trauma …

psychiatryemergency medicinediagnosticcommunicationdiazepam
SAmental health2023-03-03

Coroner's Finding: Paxford, Mathew George

27y · Male·hanging

…ervations to 15-minute intervals. However, he was left alone for 10-20 minutes while paperwork was being completed, during which time he hanged himself using a bedsheet from the ensuite bathroom door. The coroner found …

psychiatryemergency medicinecommunicationsystemdiazepam
NSWhospital2018-05-03

Inquest into the death of Naomi Watson Ley

33y · Female·hanging, self-inflicted with intention of taking her own life

…ays with instructions to avoid antidepressants for one week, then restart citalopram at 10mg. She died by suicide 2 days post-discharge. Critical clinical lessons: (1) discharge staff failed to obtain the June 2013 Nort…

psychiatryemergency medicinediagnosticcommunicationmoclobemide
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…

psychiatrygeneral practicediagnosticcommunicationescitalopram
NSWcommunity2014-12-18

Inquest into the death of Kenneth MAWBY

59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…

A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease.…

neurologyneurosurgerycommunicationsystemmadopar
QLDhome2011-11-04

Schumacher, Ross Philip

40y · Male·gunshot wound to the head

…counts. The coroner could not definitively determine cause due to investigation failures, though excluded suicide as most likely. Police supervision of the sole investigator was inadequate despite 27-month delays and id…

forensic medicinediagnosticcommunication
VICmental health2015-05-07

Finding into death of Narelle Ena Clancy

49y · Female·Hanging

… and died by hanging. She had a long history of depression and suicidal ideation following her daughter's suicide in 1999. While the decision to invoke involuntary status was based on sound clinical reasoning, critical …

psychiatrycommunicationsystemolanzapine
VICpsychiatric inpatient unit2020-01-31

Finding into death of Damon Brenden Amiet

25y · Male·Injuries sustained when struck by a train (suicide)

…sonality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serious suicide attempt by hanging. He died the next day after being struck by a train. Critical deficiencies were identi…

psychiatryemergency medicinecommunicationsystemolanzapine
VIChome2020-11-10

Finding into death of Mr BT

27y · Male·Hanging

…ic issues emerged: Victoria Police's L17 risk assessment form was incompletely filled regarding his known suicide risk and mental health history, and Child Protection did not adequately establish safety plans for the ch…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VIChome2022-08-31

Finding into death of B L

28y · Male·neck compression consequent upon hanging

…nt suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide threats and high-lethality attempts, then discharged on 27 February with brief ACIS follow-up. Key clinic…

psychiatryemergency medicinecommunicationsystemsodium valproate
WA2024-06-12

Inquest into the Death of Petra Michelle MARQUIS

40y · Female·ligature compression of the neck (hanging)

…of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being charged with drink-driving. She had been arrested with a blood alcoho…

psychiatryemergency medicineduloxetine
SA2009-08-07

Coroner's Finding: SCIACIA Marcielo Marstroianani

29y · Male·acute neck compression due to hanging

…hildren and made multiple phone calls expressing suicidal ideation. The prison stress screening form was completed with findings indicating risk, but the correctional officer misunderstood the form and did not flag him …

systemcommunication
VICcommunity2024-08-07

Finding into death of Jason

50y · Male·Neck compression secondary to hanging

…plans and clear protocols for personal safety alarm response in family violence contexts. Jason had prior suicide attempts, depression, alcohol use disorders, history of perpetrating violence, and recent relationship se…

general practicepsychiatrysystemcommunicationvenlafaxine
SAhospital2016-07-13

Coroner's Finding: NOAKES Geoffrey Scott

43y · Male·acute neck compression due to hanging

Geoffrey Noakes, a 43-year-old man with a long history of depression and suicide attempts, was detained under the Mental Health Act on 19 February 2013 after multiple suicide attempts (k…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

…charge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisation, staff assessed him as improving and low ri…

psychiatryemergency medicinecommunicationsystemvenlafaxine
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

…ive jealousy, and controlling behaviours, though no prior physical violence occurred. Coman had attempted suicide days before the homicide after the relationship ended. Eastern Health admitted Coman to the mental health…

psychiatryemergency medicinediagnosticcommunicationsertraline
WAmental health

Inquest into the Death of Vincent Tavita Tolai SCHWENKE

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

…it as an involuntary patient. Despite initial improvement and no overt behavioural indicators of imminent suicide risk, he hanged himself using a ligature fashioned on a shower head. The coroner found hospital care was …

psychiatryneurologyescitalopram
NSWhome2014-04-24

Inquest into the death of SS

50y · Female·Cyanide toxicity

…ded the manner of death was accidental drug overdose, noting she may have intended self-harm rather than completed suicide. Both Sigma-Aldrich and the NSW Pharmaceutical Services Unit implemented substantial procedural …

psychiatrypsychologysystempotassium cyanide
VICcommunity2025-11-18

Finding into death of Darren John Atkinson

50y · Male·Mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine); cardiac hype…

A 50-year-old man with treatment-resistant schizoaffective disorder died from mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine) combined with cardiac hypertrophy. He ceased his antipsychotic medication o…

psychiatryemergency medicinecommunicationsystemclozapine

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