Coronial

346 results for mental health distress

SAhome2023-06-30

Coroner's Finding: Doran, Shane Michael

54y · Male·hanging

…ion with electronic monitoring on 21 July 2020. His Community Corrections officer appropriately encouraged mental health support, and Mr Doran attended general practitioners who found no evidence of mental health issues …

general practicepsychology
NSWmental health2020-02-07

Inquest into the death of Chella Leijten

57y · Female·metastatic lung carcinoma

…lted from natural disease progression. An inquest was mandatory as she died in lawful custody (involuntary mental health detention).

psychiatrypalliative care
QLDhome2016-05-03

Tauati, Tui Dace - Non-inquest findings

21y · Male·hanging

…entified high-risk factors for suicide (young male in post-separation period, substance use, relationship distress, possible depression), no systemic failures in suicide prevention were identified. Clinical lessons inclu…

systemmethamphetamine
VICcommunity2023-07-28

Finding into death of Marcus William Caldwell

27y · Male·Hanging

…ped significant workplace stress from December 2017 onwards, characterised by burnout, fatigue, and moral distress—feeling unable to provide adequate animal care due to understaffing. His emotional decline was not consis…

psychiatrygeneral practicesystemcommunicationclozapine
NSW2025-03-06

Inquest into the death of Muhammad Hafizuddin Bin Zaini

29y · Male·hanging

…e-induced psychotic disorder and was prescribed antipsychotic medication. The inquest examined whether his mental health care was adequate and whether communication regarding repatriation was appropriate. Expert psychiat…

psychiatrygeneral practicecommunicationolanzapine
VICcommunity2021-06-28

Finding into death of Sestilio Malaspina

74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…

…n SIU procedures, intelligence gaps, delayed CVE referral, and premature risk downgrading were identified. Mental health concerns were noted but not conclusively linked to the attack. The police response was appropriate …

psychiatryemergency medicinesystemcommunicationcannabis
SAhome2025-11-27

Coroner's Finding: Nguyen, Van Tam

47y · Male·self-inflicted stab wound to the chest with penetration of the left ventricle of…

…sual hallucinations. He attended a Community Corrections appointment on 13 December appearing well with no mental health concerns identified. He died on 14 December 2022. The coroner found no failures in Community Correc…

correctional healthpsychiatryheroin
NSW2015-06-16

Inquest into the death of AB

34y · Male·Hanging

… was not identified as self-harm risk. In the weeks before his death, telephone records showed escalating distress about potential lengthy sentences, including explicit statements about not surviving life imprisonment. A…

psychiatrycorrectional healthcommunicationsystem
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…

…fear of losing contact with his young daughter, recent arrest on domestic violence charges, and historical mental health challenges including anxiety. In the days before disappearance, he had appropriately sought profess…

general practicepsychologymethamphetamine
TAShome2023-06-19

Coroner's Finding: Dawson, Andrew

44y · Male·Methamphetamine toxicity

…eavy illicit drug use, and a recent suicide attempt by overdose in September 2021. Following relationship distress and suicidal text messages, he likely used methamphetamine in the early-to-mid afternoon of 11 December a…

methamphetamine
WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

Guido Michel, a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 …

psychiatrygeneral practicesystemcommunicationdextroamphetamine
VIChome2018-07-10

Finding into death of Shrihan Gannaram

0y · Male·Multiple injuries sustained from impact with the ground from an extended height …

…riencing postpartum depression and social isolation (with only one friend in Australia), had no identified mental health issues at the four-week postnatal check. She died by suicide within days of the child's death. The …

paediatricsobstetricssystem
WA2022-02-09

Inquest into the Suspected Death of Yaritosai TOMIOKA

47y · Male·unascertained; manner of death suicide by going overboard into the ocean

…occupational and psychological pressures faced by seafarers in isolated environments and the importance of mental health support and early intervention when crew members show signs of distress related to work responsibil…

WAcommunity2025-09-17

Inquest into the Suspected Death of Wayne Michael PARKER

60y · Male·Unknown; likely suicide but natural causes or accident cannot be excluded

… about 3 June 2023, likely by suicide, though natural causes or accident cannot be excluded given his poor health and difficult terrain. No clinical errors or systemic failures in medical care were identified; the case h…

pain medicinegeneral practiceoxycodone
SA2020-05-08

Coroner's Finding: ALI Safar

25y · Male·compression of the neck due to hanging

…thin weeks and placed in a working division in a single cell. On the day of death, he returned from court distressed after reading a newspaper article about his trial. He was found hanging from a bedsheet suspended from …

SAhospital2020-07-09

Coroner's Finding: SHAW Laurel Jean

84y · Female·multi-organ failure arising from Staphylococcal septicaemia

…, aged 84, died from multi-organ failure secondary to Staphylococcal septicaemia. She was detained under a Mental Health Act order for Lewy Body Dementia when she developed MRSA pneumonia and sepsis on 15 May 2018. She w…

intensive carepsychiatry
VICcommunity

Finding into death of Jacob Anton Van Berlo

19y · Male·Hanging (self-inflicted)

…inical management of depression occurred, there was no documented crisis intervention, risk assessment, or mental health follow-up after he expressed grave concerns about gambling temptation on 9 May. The case highlights…

general practicepsychologycommunicationsystemsertraline
VIChospital2025

Finding into death of Ms NXA

54y · Female·neck compression secondary to hanging

Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt …

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
NSWcommunity2017-11-22

Inquest into the death of R P

Unknown·Hanging

…ng questions about police response protocols when individuals may be experiencing psychological crisis or distress, and the potential for de-escalation strategies.

NSWhospital2015-05-22

Inquest into the death of AB

33y · Male·Multiple injuries sustained from falling from height (fifth-floor window ledge) …

…es formal systems to ensure continuity of care—AB's ongoing Quetiapine medication was unknown at VIDC; (2) Mental health assessment conducted under restrictive security conditions (guards present, through cell door slots…

psychiatrygeneral medicinecommunicationsystemquetiapine

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