Coronial

58 results for possible acute mental illness

WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thiorid…

general practicepsychiatrythioridazine
WAhome2005-07

Inquest into the Death of taylor

29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath

Louis Bernard Taylor, a 29-year-old Aboriginal male, died from a penetrating wound to the neck inflicted by himself on 23 August 2002. Recently released from prison after four years incarceration, Louis was attempting to…

psychiatrygeneral practicecannabis
NThospital2024-04-05

Inquest into the death of Xysz Tacdliwaazy @Josh Ngalarina

22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)

A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block…

psychiatryemergency medicinediagnosticcommunicationolanzapine
WAhome2021-03-25

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

35y · Female·multiple injuries sustained in fall from sixth-floor balcony

…sors, especially those with poor insight into their condition; (3) failure of communication between GP and mental health services—Dr B. made multiple referrals to Mirrabooka Clinic but received no engagement; (4) the hig…

psychiatrygeneral practicecommunicationsystemlithium
NTmental health2019-09-27

Inquest into the death of Jordan Allen

34y · Male·self-inflicted hanging

34-year-old Jordan Allen died by suicide on 1 February 2018 after absconding from Alice Springs Mental Health Unit during supervised cigarette leave. He was acutely psychotic with persecutory delusions related…

psychiatryemergency medicineclinicalcommunicationdexamphetamine sulfate
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

…e to mixed prescription drug sedation (clozapine and olanzapine) in the presence of advanced emphysema and acute bronchopneumonia. He was admitted to Spencer Clinic psychiatric inpatient unit following an assault on sta…

psychiatryemergency medicinemedicationdiagnosticclozapine
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

…tric assessment, he was discharged without admission. A critical failure occurred on 24 September when the mental health team's decision to 'await recontact' rather than assertively intervene, despite clear family concer…

psychiatryemergency medicinediagnosticsystemcannabis
VICmental health2018-09-17

Finding into death of Paquita Goldberg

87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…

…a, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February 2013, she experienced escalating distress, disclosed prior sexual trau…

psychiatrygeriatric medicinecommunicationsystemdesvenlafaxine
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
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

…entre. Despite a history of depression with previous suicidal ideation, SJ was assessed as low-risk by his mental health team and appeared clinically stable and engaged with staff on the morning of his death. The coroner…

psychiatryhaematologycommunicationdelaymetoclopramide
VICmental health2022-12-12

Finding into death of Scott Adam Brown

50y · Male·Hanging

…kinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary to Parkinson's disease and its treatments rather than primary psyc…

psychiatryneurologysystemcommunicationmadopar
WAmental health2021-10-22

Inquest into the Death of Russell David BROCKLISS

38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…

… and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute cardiac arrhythmia while in mental health involuntary care. He was admitted to the High Dependency Unit af…

psychiatryemergency medicinedelaysystemrisperidone depot
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

…es), and his underlying heart disease. Critical failures included: no ambulance called early despite known mental health crisis; inadequate police supervision and communication; failure to monitor breathing during prone …

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol
WAcommunity2017-09-06

Inquest into the Death of Mamadou Hady DIALLO

39y · Male·multiple injuries from motor vehicle collision

A 39-year-old man with chronic paranoid schizophrenia on a Community Treatment Order died by suicide in a head-on motor vehicle collision. He had been appropriately managed on depot antipsychotic medication with generall…

psychiatrygeneral practicecommunicationdiagnosticrisperidone
NSWmental health2011-06-23

Djordevic final

32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …

…-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unaware of her mental illness. After delivery, she…

obstetricsgeneral practicecommunicationsystemclozapine
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
QLDhospital2008-12-15

Harris, Robert

60y · Male·asphyxia sequential to hanging due to depression

…une 2006, he was discharged from Cairns Base Hospital Emergency Department with a plan to attend community mental health the following morning. However, he died by hanging on 28 June 2006. Key clinical lessons include: t…

psychiatryemergency medicinecommunicationdiagnosticfluvoxamine
QLDcommunity2006-12-15

Barlow, Charles Edward; Lusk, Patrick Douglas; Baggott, Emily Jane

asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …

Three linked suicide cases spanning February 2004 to October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairn…

psychiatrygeneral practicediagnosticcommunicationflupenthixol

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