Coronial

690 results for hanging

VICpsychiatric hospital ward2013-03-13

Finding into death of Justin John Fraser

35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…

… first-episode psychosis admitted to Frankston Hospital psychiatric unit, was found attempting suicide by hanging and subsequently became agitated. Security and AMT staff physically restrained him after a code grey aler…

psychiatryemergency medicinecommunicationsystemolanzapine
QLDhospital2008-12-15

Harris, Robert

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

…gency 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: the suicide note and isolated location of the first attemp…

psychiatryemergency medicinecommunicationdiagnosticfluvoxamine
ACTmental health2015-06-15

AN INQUEST INTO THE DEATH OF PETER ZOVAK

46y · Male·asphyxia by hanging

Peter Zovak, a 46-year-old with substance use history, presented to mental health services in November 2013 with first-episode psychosis. After initial hospital assessment and two CAT Team visits, his case was closed on …

psychiatryemergency medicinediagnosticcommunicationcannabis
NTcommunity2009-06-04

Inquest into the death of Kunmanara Forbes

15y · Female·Hanging (self-inflicted)

A 15-year-old Aboriginal girl in a remote Central Australian community died by suicide following a year marked by petrol sniffing, sexual abuse concerns, and reported suicide attempts. She suffered multiple sexually tran…

paediatricspsychiatrycommunicationsystem
NSWhospital2015-07-02

Inquest into the death of N

69y · Female·Asphyxiation consistent with hanging

A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…

neurologypsychiatrydiagnosticcommunicationphenytoin
VICpsychiatric inpatient unit2020-01-31

Finding into death of Damon Brenden Amiet

25y · Male·Injuries sustained when struck by a train (suicide)

…s admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serious suicide attempt by hanging. He died the next day after being struck by a train. Critical deficiencies were identified in his clinica…

psychiatryemergency medicinecommunicationsystemolanzapine
WA2019-05-09

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

36y · Male·Ligature compression of the neck (suicide by hanging)

A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remande…

psychiatryforensic medicinecommunicationsystemmethamphetamine
NSW2023-07-06

Inquest into the death of RRC

26y · Male·hanging, intentionally self-inflicted

A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…

psychiatrycorrectional healthcommunicationdocumentation
WAhome2020-07-16

Inquest into the Death of CHILD RM

17y · Female·ligature compression of the neck (hanging)

A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…

paediatricspsychiatrysystemcommunicationalcohol
NSW2019-10-25

Inquest into the death of R N

58y · Male·asphyxiation by ligature

A 58-year-old Cambodian male with basic English skills died by suicide in prison after 7 days in custody on remand for assault. Critical failures in the reception screening process included: incomplete identification and…

psychiatrycorrectional healthcommunicationsystem
VIC2022-07-15

Finding into death of Noel Thomas

42y · Male·hanging

Two prisoners at Karreenga Correctional Centre died by suicide within four months of each other. Mr Lowe, aged 35, hanged himself on 7 March 2017 after learning his prison sentence would be longer than expected. Mr Thoma…

psychiatrycorrectional healthsystemcommunication
NTcommunity2018-12-03

Inquest into the death of Sabrina Di Lembo

19y · Female·self-inflicted hanging

Sabrina Di Lembo, a 19-year-old law student, died by suicide after experiencing anxiety and panic attacks during exam preparation. Over nine weeks, she had 17 medical contacts but received inadequate assessment, no detai…

general practicepsychiatrydiagnosticmedicationvenlafaxine
NT2012-03-07

Inquest into the death of Robert Martin Johnson

34y · Male·asphyxiation by hanging

A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …

psychiatrygeneral practicediagnosticsystem
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

Sean Collins, 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…

general practicepsychiatrydiagnosticcommunicationsertraline
WAcommunity2019-07-17

Inquest into the Death of Mark Quenton FLEURY

38y · Male·ligature compression of the neck (hanging)

Mark Quenton Fleury, a 38-year-old man with paranoid schizophrenia, died by suicide on 14 February 2016 while subject to a Community Treatment Order. In the final week of his life, he presented to emergency services and …

psychiatryemergency medicinecommunicationsystemrisperidone
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

Natasha Quartermaine, a 25-year-old female prisoner at Bandyup Women's Prison in Western Australia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, person…

psychiatrygeneral practicecommunicationsystemzuclopenthixol
VIChome2018-10-03

Finding into death of Yvonne Rose Vizard

72y · Female·Obstruction of the airways of the neck

…e-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies were identified in post-stroke men…

neurologyrehabilitation medicinediagnosticsystem
VIChome2020-04-07

Finding into death of Jesse Stephen Bird

32y · Male·neck compression in the circumstances of hanging

Jesse Bird, a 32-year-old Torres Strait Islander veteran, died by suicide in June 2017 after struggling to navigate the Department of Veterans' Affairs (DVA) compensation system. He served in Afghanistan in 2009, develop…

psychiatryparamedicinesystemcommunicationduloxetine
NSW1979-09-03

Inquiry into the fire and deaths at Luna Park

Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…

… and absence of smoke alarms or evacuation procedures. The building's maze-like layout, darkness, and low-hanging smoke made escape extremely difficult. The coroner found a serious breach of duty of care by Luna Park ma…

systemdelay
VIC2017

Finding into death of Jacinta Mary Dwyer

50y · Female·Hanging

Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…

psychiatrygeneral practicesystemcommunicationcitalopram

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