Coronial

690 results for hanging

WA2016-10-07

Inquest into the Death of Gerardus Gerritt HEIJNE

49y · Male·Ligature compression of the neck (hanging)

A 49-year-old sentenced prisoner died by suicide via ligature compression of the neck at Acacia Prison in Western Australia. The deceased had a psychological profile characterised by denial and minimisation of adverse ex…

psychiatrygeneral practicedelaycitalopram
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidalit…

psychiatryemergency medicinecommunicationsystemvenlafaxine
WAcommunity2022-12-12

Inquest into the Death of Lewis Henry Mark WESTON

22y · Male·ligature compression of the neck (hanging)

Lewis Weston, aged 22, died by suicide on 3 November 2020 while subject to a Community Treatment Order (CTO) for Schizoaffective Disorder. He presented with first-episode psychosis in 2017 and repeatedly refused antipsyc…

psychiatryemergency medicineolanzapine
WAhome2014-10-17

Inquest into the Death of Ethan (Subject to a Suppression Order)

15y · Male·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal boy in foster care died by suicide following apparent impulsive response to adolescent boundary conflicts. Despite stable, loving foster placement since age 4, Ethan remained neurologically vulne…

psychiatrypsychologymelatonin
WAhome2013

Inquest into the Death of Hurley-Goodacre, Adam Michael

17y · Male·Ligature Compression of the Neck (Hanging) - Suicide

Adam Hurley-Goodacre, a 17-year-old Ward of the State since 1996, died by suicide on 20 February 2007, one week before his 18th birthday. He had a history of suicide attempts in October 2006 while experiencing emotional …

paediatricspsychiatrysystemalcohol
SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She ha…

general practiceemergency medicinediagnosticproceduralparacetamol
NSWmental health2020-11-27

Inquest into the death of JP

46y · Female·hypoxic brain injury due to hanging

A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…

psychiatryemergency medicinecommunicationprocedural
WAhome2024-09-11

Inquest into the Death of Stephen Kenneth SHERWOOD

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

Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted suicide by wrist-cutting on 30 March 2022 and th…

psychiatryemergency medicinecommunicationmethamphetamine
WAhome2018-06-27

Inquest into the Death of Brook Damian CAIN

39y · Male·ligature compression of the neck (hanging)

A 39-year-old man with schizoaffective disorder and substance abuse died by suicide following arrest for criminal damage. While treated under a Community Treatment Order, he had poor medication compliance and ongoing dru…

psychiatryemergency medicinecommunicationsystemquetiapine
SAhospital2000-05-31

Coroner's Finding: DELLATORRE Natale

54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…

…ury to his left thigh sustained while attempting to escape from a psychiatric hospital. He became trapped hanging upside down on a perimeter fence on 19 January 1997. Initial assessment at Royal Adelaide Hospital ED mis…

emergency medicinepsychiatrydiagnosticadrenaline
VICmental health2025-02-27

Finding into death of Judith Mary Pollard

73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…

…wing acute depression and paranoia. Despite her family informing staff of her previous suicide attempt by hanging in hospital and requesting close monitoring, she was placed on 30-minute observation intervals. On 2 June…

psychiatryemergency medicinesystemcommunicationamitriptyline
VIChome2011-08-09

Finding into death of Patricia Webster

41y · Female·Hanging

Patricia Webster, a 41-year-old with a history of major depressive disorder, was admitted to hospital on 8 October 2009 after stopping antidepressants. She was discharged on 21 October with community mental health follow…

psychiatrygeneral practicecommunicationsystemantidepressants
QLD2012-08-07

Bucknall, David John

41y · Male·Hanging

A 41-year-old male prisoner with a history of depression died by suicide while incarcerated at Wolston Correctional Centre. He was appropriately assessed as low-risk for suicide on arrival and received psychiatric care a…

psychiatrygeneral practicesystemdelaymirtazapine
VIChome2021-12-17

Finding into death of B H

49y · Male·hanging

A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that h…

psychiatrypsychologycommunicationsystemantidepressant medication
NSW2022-08-26

Inquest into the death of LAK

19y · Male·Hanging

LAK, a 19-year-old Aboriginal man, died by suicide at a community rehabilitation facility after a complex mental health journey involving forensic orders and psychosis. Key clinical lessons include: recognising vulnerabi…

psychiatryaddiction medicinecommunicationsystem
NSW2022-10-12

Inquest into the death of Brenden Montgomery

36y · Male·Hypoxic Ischaemic Encephalopathy

Brenden Montgomery, aged 36, died from hypoxic ischaemic encephalopathy after hanging himself on 30 December 2019 while police were present outside his home. He had a long-standing history of…

communicationsystemescitalopram
VICcommunity2017-04-05

Finding into death of KP

15y · Male·Hanging (redacted in original but indicated by reference to method of suicide)

A 15-year-old boy with depression died by suicide. He had a difficult relationship with his parents and was reluctant to engage with mental health services. A clinical psychologist assessed him as low-moderate suicide ri…

psychologypsychiatrycommunicationsystem
WAcommunity2008-02-25

Inquest into the Death of Kimberley Coronial Report

Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…

…ol and cannabis abuse. The primary cause of death across most cases was ligature compression of the neck (hanging). The inquest revealed appalling living conditions in Aboriginal communities: extreme poverty, overcrowde…

public healthpsychiatrysystemdelayalcohol
WAmental health- 11 April 2014

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

…onia with background ischaemic heart disease, chronic renal failure, and hypoxic brain injury from a 1985 hanging attempt. She had been an involuntary patient at Graylands Hospital since 1987. The coroner found that sta…

psychiatrygeneral medicinesystemdelaylithium
VIC2012-09-21

Finding into death of Timothy Casey

41y · Male·Hanging

…year-old remand prisoner with a history of major depressive disorder and drug/alcohol dependence, died by hanging in Port Phillip Prison in March 2008. The coroner identified multiple system failures: psychiatric assess…

psychiatrycorrectional healthdiagnosticcommunication
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