Coronial

746 results for psychiatric treatment

VIChome2026-06-09

Finding into death of A T

42y · Male·Gunshot injury to the head

… diagnosed depression, adjustment disorder, and ketamine abuse beginning in 2019. He received inpatient psychiatric treatment in August 2021. On 20 December 2024, following a family celebration and heavy drinking, AT ar…

psychiatrysystemketamine
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

…izophrenia, died by suicide on 1 November 2021 after self-immolating with boat fuel while on a Community Treatment Order. Wilson was discharged from Graylands Hospital on 29 October 2021 following a 12-day admission for…

psychiatryintensive carecommunicationsystempaliperidone
VIChospital2014-05-14

Finding into death of Palma Castro

26y · Female·compression of the neck consequent upon hanging

Palma Castro, a 26-year-old woman with adjustment disorder and benzodiazepine dependence, died by hanging after two Emergency Department presentations within 5 hours on 17-18 February 2011. She presented following a suic…

psychiatryemergency medicinecommunicationdocumentationalprazolam
VIChome2014-11-11

Finding into death of Tamara Ann Burt

32y · Female·Alcoholic ketoacidosis

…lcohol dependence disorder, and borderline personality disorder traits. Despite outpatient mental health treatment through MSTS and alcohol counselling through EDAS, her care was fragmented across three separate service…

psychiatryaddiction medicinesystemcommunicationquetiapine
WAhospital2011-11-22

Inquest into the Death of Ashdown

27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…

Warwick Andrew Ashdown, a 27-year-old male with severe treatment-resistant paranoid schizophrenia, died at Graylands Hospital on 12 October 2007 from cardiac arrhythmia …

psychiatryintensive careproceduralsystemhaloperidol
VICcommunity2015-09-24

Finding into death of GC

42y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

…t his risk to self and others, he was assessed as not meeting Mental Health Act criteria for involuntary treatment two days before his death. Mental health services attempted limited outreach without success. On 19 Janu…

psychiatryemergency medicinesystemdelaycannabis
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

…onse to multiple undisclosed suicide attempts and self-harm incidents; (4) lack of focused psychological treatment; (5) absence of a key worker relationship; (6) poor integration with emergency services. The coroner con…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
VIChome2021-03-19

Finding into death of Kim Melissa Hall

36y · Female·combined effects of baclofen toxicity and blunt head injury

…lofen toxicity can cause profound CNS depression and seizures, particularly in polysubstance users with psychiatric comorbidity. Prescribing large quantities to vulnerable patients requires careful monitoring and consid…

general practiceaddiction medicinemedicationbaclofen
SAhospital2001-05-16

Coroner's Finding: KLOSE Glen Malcolm

71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…

Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Ho…

psychiatrygeneral medicinedelay
SAhospital2015-03-06

Coroner's Finding: SIMOS Theodoras Joannas

48y · Male·undetermined

…choice considering respiratory sensitivity is essential; coordination between services (local hospital, psychiatric triage, retrieval services) requires defined leadership and protocols.

psychiatrygeneral practicesystemdelayhaloperidol
VIChospital2024-07-25

Finding into death of Nathan Ruan Roy Greenwood

18y · Male·Sodium nitrite toxicity

…sons include: the importance of timely access to specialist mental health services for young people with treatment-resistant symptoms; recognising the role of social isolation and pandemic-related stressors in mental he…

general practicepsychiatrysystemdelaysodium nitrite
NSWcommunity2010-10-15

Coroner's Finding: Charmaine Margaret Dragun

29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…

Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …

general practicepsychiatrydiagnosticmedicationsertraline
NSWhospital2024-10-11

Inquest into the death of AX

45y · Female·Multiple blunt force injuries

…g shortly after and died from injuries sustained falling from a height while acutely psychotic. Earlier psychiatric scheduling when risk became apparent, immediate involvement of senior psychiatry staff, and prompt acti…

emergency medicinepsychiatrydiagnosticcommunication
NSW2020-12-11

Inquest into the death of SB -findings - 11 December 2020

38y · Male·asphyxiation by ligature

…erns with prison clinicians, being prescribed antidepressants and antipsychotics. The coroner found his psychiatric and psychological care appropriate overall, though documentation was brief. Key failures included: no m…

psychiatrypsychologycommunicationsystemmirtazapine
VIChome2021-09-21

Finding into death of Marilyn June Burdon

70y · Female·Gunshot wounds to the head and chest

…ented this death. The coroner emphasised systemic gaps rather than individual clinician error regarding psychiatric care.

psychiatryforensic medicinediagnosticsystem
QLDhome2025-10-17

Inquest into the death of Alexandria Catherine Forrester

39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…

…een prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatment Program, contrary to clinical guidelines which recommend maximum four doses per week for low-risk patien…

addiction medicinegeneral practicediagnosticmedicationmethadone
VIChospital2021-03-19

Finding into death of BT

25y · Male·Multiple system failure and ingestion of sodium nitrite

…his room and ingested it at 10:03pm. He deteriorated to cardiac arrest at 10:26pm. The critical delay in treatment occurred because venous blood gas results showing severely elevated methaemoglobin (70-86%) were not con…

emergency medicinepsychiatrydiagnosticsystemsodium nitrite
NTcommunity2011-10-11

Inquest into the death of Aaron Nathan Stagg

28y · Male·hanging

Aaron Nathan Stagg, 28-year-old man with likely Asperger's Syndrome and emerging paranoid psychosis, died by hanging on 5 March 2010 after a period of disengagement from mental health services. He was referred to Top End…

psychiatrypsychologysystemrisperidone
WAmental health2011-04-21

Inquest into the Death of Barnes

50y · Female·acute heart failure in association with acute on chronic obstructive airways dis…

Donna Lillian Barnes, a 50-year-old woman with chronic schizophrenia and multiple physical comorbidities including morbid obesity, asthma, and poor mobility, died of acute heart failure associated with acute-on-chronic o…

psychiatrygeneral medicinecommunicationsystemantibiotics
WAhospital2004-11-12

Inquest into the Death of Mortensen

60y · Female·Aspiration of food in a woman with cerebral atrophy

Jytte Mortensen, a 60-year-old woman with multi-infarct dementia and schizoaffective disorder, died at Graylands Hospital from aspiration of food. She had documented dysphagia requiring a pureed diet and one-to-one super…

psychiatryspeech pathologycommunicationsystem
133343538

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