40y · Female·combined drug toxicity (clomipramine, sertraline, diazepam, and quetiapine)
Linda-Jane Tatterson, aged 40, died from combined drug toxicity involving clomipramine, sertraline, diazepam, and quetiapine. She had a longstanding history of depression, OCD, and recurrent overdoses between 2014-2016. …
74y · Female·Subdural haemorrhage following a fall in a woman with multiple medical comorbidi…
Mrs Chettle, a 74-year-old aged care resident with multiple comorbidities including dementia, schizoaffective disorder, and a nine-fall history in twelve months, fell from a shower chair while a personal care assistant b…
Male·Multiple gunshot wounds from police shooting
Tyler Cassidy, 18, died after police shot him multiple times when he advanced on them with two knives in a public park. The coroner found that while Tyler's actions were deliberate, they were not voluntary—he was overwhe…
29y · Female·Multiple Drug Toxicity (Lamotrigine, Doxylamine, Venlafaxine, Valproic Acid, Cod…
A 29-year-old woman with personality disorders and depression called Perth Clinic at 11:11pm reporting she had overdosed on multiple medications (lamotrigine, doxylamine, venlafaxine, valproic acid, codeine, morphine). S…
18y · Female·Mixed drug toxicity
TK, an 18-year-old woman with borderline personality disorder, chronic suicidality, and a history of childhood trauma, died from mixed drug toxicity following intentional overdose. She had multiple psychiatric admissions…
32y · Male·Neck compression in the setting of hanging
Mr A, a 32-year-old male with a history of family violence perpetration, mental illness (bipolar disorder, schizophrenia, PTSD), substance misuse, and prior suicide attempts, died by hanging on 21-22 November 2020. He wa…
20y · Male·gunshot wound to the chest
…th care following emergency department discharge; recognizing the complex interplay of substance abuse, impulsivity, and mental illness in crisis presentation; and the importance of multi-agency coordination in mental h…
20y · Male·Ligature compression of the neck (hanging)
Leon John Donaldson, a 20-year-old sentenced prisoner with a documented history of self-harm, depression, and suicidal ideation, died by hanging in his cell at Casuarina Prison on 2 September 2004. He had been identified…
40y · Male·Penetrating wounds to the chest
…ecognise and act on clear signs of acute mental illness (delusions, hallucinations, disordered thought, impulsivity, unregulated emotions). They did not utilise Mental Health Act 2014 powers to apprehend him for assessm…
15y · Male·Ligature Compression of the Neck (Hanging)
Jake Dunne-Heynis, a 15-year-old Year 11 student at Exmouth District High School in rural Western Australia, died by suicide on 23 June 2004, two days after hanging himself at home. Jake had motor coordination difficulti…
13y · Female·complications of a head injury sustained when she deliberately stepped in front …
A 13-year-old with emerging emotionally unstable personality disorder (EUPD) died by suicide after deliberately stepping in front of a car on 21 July 2020, two days after a positive appointment with mental health clinici…
30y · Male·ligature compression of the neck (hanging)
…d was not detected to be taking prescribed quetiapine at time of death, worsening untreated anxiety and impulsivity. The coroner found care suboptimal but could not conclusively establish preventability, noting suicide'…
59y · Male·Drowning
Benjamin Woodhouse, a 59-year-old involuntary mental health patient with schizophrenia and a history of absconding, drowned in the Parramatta River while on escorted leave. Critical systemic failures included inadequate …
26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…
A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate …
25y · Male·Dehydration with contributory causes of severe mental health conditions and hype…
…ng the final destination or conducting timely risk assessment despite staff concerns and his history of impulsivity; (2) The location chosen (Mathoura, a border town with limited mental health services, near a national …
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental healt…
22y · Male·ligature compression of the neck (hanging)
Ricky-Lee Cound, a 22-year-old Noongar man with Foetal Alcohol Spectrum Disorder (FASD), died by suicide in Hakea Prison on 25 March 2022 from ligature compression. Critical clinical lessons emerge: (1) his FASD diagnosi…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.