Coronial

654 results for mental health issues

TAS2023-07-05

Coroner's Finding: Crump, Damian Michael

36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…

…epeatedly undetected, failure to investigate suspected drug thefts in September 2016, absence of mandatory mental health and welfare support despite widespread knowledge of Crump's suicidal plans, lack of manager trainin…

paramedicinepsychiatrysystemdelaymorphine
VIChome2019-01-10

Finding into death of Zhikai Liu

24y · Male·Multiple injuries

…015 and experienced significant stressors including language barriers, academic difficulties, relationship issues, and insomnia. His sister observed depression and suicidal ideation but he refused professional help. The …

psychiatrygeneral practicesystem
VIChospital2015-10-30

Finding into death of Avjit Singh

31y · Male·Complications of burns

… the context of family violence; separate findings into Ms Ragi's death addressed systemic family violence issues. No specific clinical or preventability issues regarding Mr Singh's medical management were identified by …

emergency medicineintensive care
TAScommunity2022-04-29

Coroner's Finding: Mawer, Stephen Charles

45y · Male·Self-inflicted burns (80-90% full and partial thickness burns across body)

… for a suicide attempt and was facing potential criminal charges for sexual offences against children. His mental health had deteriorated markedly, complicated by a video game addiction and disclosure of childhood sexual…

general practicepsychiatry
VICcommunity2018-03-14

Finding into death of C P

59y · Female·Gunshot injuries to the head

…motional family violence throughout their relationship. CP had experienced abuse since childhood, suffered mental and physical health complications, and became dependent on alcohol. She was receiving psychiatric support …

psychiatrydiagnosticcommunicationcitalopraam
VIChome2018-07-10

Finding into death of Carmelo Gusman

50y · Male·Single, contact-range shotgun discharge to the head

…on, unemployment, weapon access, and suicide risk in perpetrators of family violence. No medical errors or healthcare system failures were identified. The coroner notes the heightened suicide risk in family violence perp…

psychiatrypsychology
QLDhospital2008-12-15

Van Putten, Patricia

49y · Female·Respiratory failure sequential to ingestion of Glyphosate due to depression and …

…uded: inadequate verification of Mr Lowe-Brock's suitability as a supervisor (he later revealed unreported mental health issues), lack of written communication between hospital psychiatrists and her long-term private GP …

psychiatrygeneral practicecommunicationsystemdosulepin
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was…

psychiatryemergency medicinecommunicationsystemdiazepam
WAhome2004-10-28

Inquest into the Death of Kelly

33y · Female·Combined drug toxicity, with thioridazine as the principal component, in the con…

…n 2 April and suffered cardiorespiratory arrest. The coroner found the death accidental, not suicidal. Key issues identified included: the deceased's long-standing prescription drug and alcohol abuse despite attempts by …

general practicepsychiatrysystemthioridazine
VIChome2024-08-29

Finding into death of A S

19y · Female·sodium nitrite toxicity

…ay 2021. She ingested sodium nitrite during a video call with a friend in NSW. AS had a complex history of mental health issues (autism spectrum disorder, generalised anxiety disorder, major depressive disorder, gender d…

psychiatryendocrinologysystemsodium nitrite
VIC2020

Finding into death of Stephen Myall

59y · Male·Hanging

…nsure justice for unrepresented persons, media criticism of decisions, and concerns about systemic justice issues. He had accrued 90 days of leave but was reluctant to take it. One month before death he attended a judici…

QLDhome2022-01-18

Lewis, Daniel Patrick

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

…e responded to a domestic violence call. Lewis had a history of brain injury from age 11, substance abuse, mental health issues including PTSD and drug-induced psychosis, and was prescribed antipsychotics. On the day of …

psychiatryemergency medicinecommunicationsystemalcohol
SAhome2003-04-11

Coroner's Finding: YIALAS Dimitrios

23y · Male·neck compression due to hanging

…ad a long history of substance abuse and behavioural problems, with multiple presentations to hospital and mental health services. In March 2001, he was admitted for acute psychosis but discharged against medical advice.…

psychiatrygeneral practicecommunicationsystemamitriptyline
QLD2006-10-31

Ali-Haapala, Anita

20y · Female·injuries received from a fall from the viewing platform at Perriwen Lookout at M…

Anita Elsa Ali-Haapala, a 20-year-old with a long history of mental health issues, presented to Nambour Hospital on 17 May 2005 expressing suicidal ideation. She was admitted…

psychiatrydelaysystem
VICcommunity2024-08-29

Finding into death of Bridget Flack

28y · Female·compression of the neck and hanging

28-year-old Bridget Flack, a transgender woman experiencing complex mental health issues including depression, anxiety, borderline personality disorder and PTSD, died by suicide in …

psychiatrypsychologycommunicationsystemescitalopram
QLDcommunity, community, community2019-08-30

Nebauer, Talieha; Fowell, William and Whiticker, Caitlin Wilkinson

18y · Female, female, male·Caitlin: suicide by hanging; Talieha: suicide by hanging; William: suicide by tr…

…ide within four months of the Barrett Adolescent Centre (BAC) closure in January 2014. Caitlin had complex mental health needs including bipolar affective disorder and PTSD; she lived with her mother and a family member …

psychiatrypsychologycommunicationsystem
QLDmental health2024-09-17

Inquest into the death of Chloe Jane Campbell

32y · Female·Hypoxic-ischaemic encephalopathy due to hanging

…xic brain injury and cardiac arrest; died 30 April. Coroner found treatment appropriate but noted systemic issues: ensuite doors represented known ligature risk (identified in 2015 and 2018 audits marked for 'local manag…

psychiatryintensive caresystemlorazepam
NSWhome2019-02-26

Inquest into the death of Emily

Female·self-inflicted death

…sons: (1) Complete medical and psychological histories must be shared with treating clinicians—Emily's new healthcare providers lacked prior reports; (2) Schools must receive written information about children's mental h…

psychologypsychiatrycommunicationsystem
VIChome2018-12-07

Finding into death of Wayne Brown

38y · Male·Stab wound to the chest

… with significant risk factors including substance misuse (alcohol, methamphetamine, cannabis, methadone), mental health issues, unemployment, controlling and jealous behaviour towards his ex-partner, and suicidal ideati…

alcohol
TAScommunity2026-02-23

Coroner's Finding: de-identified VY

33y · Female·hanging

A 33-year-old woman with significant history of mental health issues, depression, anxiety, suicidal ideation and prior suicide attempts died by hanging while hig…

psychiatryemergency medicinesystemalcohol

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