24y · Female·hypoxic brain injury secondary to hanging
Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination er…
32y · Male·self-inflicted hanging
…lins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence uncert…
46y · Male·complications of ligature compression of the neck (hanging)
Sean Theo Winmar, a 46-year-old Nyungar Aboriginal man, died by hanging at The Beacon residential facility on 11 August 2022. He was subject to an interim post-sentence supervis…
43y · Male·Hanging
…plex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in Goulburn Correctional Centre after 183 days in custody. The critical failure was the systemic denial o…
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairne…
50y · Female·Hanging
…r judges and mental health treatment for major depressive disorder, she resigned in July 2017 and died by suicide in October 2017. The coroner found medical care was appropriate and identified no missed opportunities in…
79y · Male·external neck compression as a result of hanging
…ear-old man with bipolar affective disorder and a documented history of medication non-compliance died by suicide while living in rural NSW. He had been subject to a Victorian Community Treatment Order (CTO) requiring f…
38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…
…ct during a critical period, particularly during a poorly managed caseworker handover. While the homicide-suicide could not have been predicted, earlier multidisciplinary coordination, more robust psychiatric oversight …
34y · Male·Hanging
Errol Handog, a 34-year-old man presenting with anxiety, was assessed by psychiatry on two consecutive days at Nepean Hospital and discharged to community care despite suicidal ideation. A key clinical lesson is that inc…
27y · Male·Hanging
Richard Hilton, a 27-year-old with longstanding bipolar affective disorder and benzodiazepine dependence, presented to Werribee ED three times in two months with suicidal ideation and self-harm attempts. Each time he was…
42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…
…ioulios, a 42-year-old psychologist, died from hypoxic ischemic encephalopathy following a self-inflicted hanging in a Corrective Services transport vehicle on 4 July 2008. She had presented to mental health services th…
59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…
A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease.…
23y · Male·Hanging whilst suffering acute mental illness, most likely a first episode delus…
A 23-year-old man in custody died by hanging in May 2011 while experiencing untreated first-episode psychosis with paranoid delusions. He had expresse…
41y · Female·ligature compression of the neck (hanging)
…o low without documented justification. Ward 6 was under-resourced with acutely unwell patients. Although suicide remains difficult to predict, these systemic failures represented missed opportunities for enhanced care.…
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 FAS…
33y · Female·hanging, self-inflicted with intention of taking her own life
…ays with instructions to avoid antidepressants for one week, then restart citalopram at 10mg. She died by suicide 2 days post-discharge. Critical clinical lessons: (1) discharge staff failed to obtain the June 2013 Nort…
Male·neck compression due to hanging
Two men died by suicide within five months of emergency department assessments at Lyell McEwin Hospital. Both had been brought in…
27y · Male·compression of the neck due to hanging
…ith worsening suicidal ideation and depression but was inadequately assessed and not admitted. He died by hanging on 24 January 2016. Key failures: inadequate consideration of longitudinal history, premature discharge w…
48y · Female·Neck compression secondary to hanging
Ms HRZ, a 48-year-old Turkish-born woman, died by suicide on Christmas Day 2020 after experiencing years of family violence. She first endured abuse from her ex-hu…
47y · Male·ligature compression of the neck (hanging)
A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation,…
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