Coronial

746 results for psychiatric treatment

SAhospital2016-07-13

Coroner's Finding: NOAKES Geoffrey Scott

43y · Male·acute neck compression due to hanging

Geoffrey Noakes, a 43-year-old man with a long history of depression and suicide attempts, was detained under the Mental Health Act on 19 February 2013 after multiple suicide attempts (knife to throat, jumping from vehic…

psychiatryemergency medicinediagnosticcommunicationolanzapine
NSWmental health2025-03-28

Inquest into the death of NL

62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval

…ive clinical review not passive endorsement; abnormal results must trigger discussion at team meetings; psychiatric units managing medically complex patients need robust systems to ensure medical escalation; observation…

psychiatryendocrinologydiagnosticcommunicationthyroxine
WA2000-04-07

Inquest into the Death of Kenneth John Groth

47y · Male·Ligature compression of the neck (hanging)

…ignificant distress. The coroner found he died by suicide. While finding no systemic failures in medical treatment or prison supervision, the coroner identified a critical care issue: Groth was placed in medical observa…

psychiatrycorrectional healthdiagnosticfluoxetine
VIC2024

Finding into death of W B

59y · Male·Gunshot wound of head

A 59-year-old police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP ma…

general practicepsychiatrycommunicationsystemdiazepam
NSWcommunity2025-09-08

Inquest into the death of Rohan Lloyd

37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …

…ternative theories (autism/anxiety) without robust diagnostic evidence; family counselling and community treatment orders should be considered when patients discontinue essential medications. The coroner found no clinic…

psychiatrygeneral practicediagnosticmedicationrisperidone
VICcommunity2015-04-13

Finding into death of KJ

18y · Female·Multiple injuries due to impact by train

KJ was an 18-year-old girl who died by suicide by train on 30 November 2012, six months after a suicide attempt. She had a complex trauma history, including childhood sexual abuse aged 6, and subsequently developed depre…

psychiatrygeneral practicediagnosticcommunicationfluoxetine
NSW2019-02-15

Inquest into the death of Paul Lambert

36y · Male·Combined effect of gunshot wounds to the chest and abdomen

Paul Lambert, 36, was shot by NSW Police on the Pacific Highway after attacking and stabbing his former girlfriend Dr J. multiple times. He had a longstanding pattern of intimate partner violence, stalking, emotional abu…

psychiatrygeneral practicesystemdelayolanzapine
VIChome2023-10-17

Finding into death of J H

15y · Male·Electrocution

…September 2019. He had been experiencing suicidal ideation for months and was discharged from inpatient psychiatric care (Stepping Stones) on 19 August 2019 after a paracetamol overdose. Community mental health follow-u…

psychiatrypaediatricssystemcommunicationfluoxetine
VICaged care2010-09-08

Finding into death of Joan Hendrickson

78y · Female·Aspiration pneumonia, epistaxis, and trauma to the face

…ral practitioner failed to coordinate risk assessments or refer JL to the Aged Psychiatry Assessment and Treatment Team (APATT) despite clear indicators. Had APATT been engaged earlier, appropriate management strategies…

general practicegeriatric medicinecommunicationsystem
WAmental health- 11 April 2014

Inquest into the Death of Aaron Luke PRISGROVE

32y · Male·ligature compression of the neck (hanging)

Aaron Luke Prisgrove, a 32-year-old man with depression, alcohol abuse, and acromegaly, died by hanging on 12 July 2011, shortly after involuntary admission to Graylands Hospital's Smith Ward. He had presented to Tom Pri…

psychiatryemergency medicinecommunicationsystemparacetamol/codeine
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
VICmental health2024-04-26

Finding into death of Allison Leah Randall

37y · Female·Hanging

…oman with a history of anxiety, depression, and childhood trauma, was admitted to the Northern Hospital psychiatric unit on 15 May 2020 following acute concerns about her partner's behaviour towards their daughter. She …

psychiatrysystemdiazepam
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

31-year-old George Grimes with longstanding schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with …

psychiatryemergency medicinediagnosticcommunicationquetiapine
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIChome2014-03-06

Finding into death of Kylie Jane Fowler

36y · Female·Effects of Fire

…ages 11, 13, and 18) in a house fire with stab wounds on 9 January 2011. Ms Fowler had five involuntary psychiatric admissions but consistently rejected treatment, had poor medication compliance, and was never engaged w…

psychiatrygeneral practicecommunicationsystemrisperidone
TASPodcast2025-06-19

Coroner's Finding: Findings in relation to Shane Navin, Leigh Mundy, Dennis Neagle and Anthony Seymour

Multiple causes: Shane Navin - drowning; Leigh Mundy and Dennis Neagle - multipl…

A comprehensive coronial inquest into four deaths at Targa Tasmania motorsport events (2021-2022). Shane Navin drowned after his vehicle crashed into a creek; Leigh Mundy and Dennis Neagle died in a high-speed crash due …

diagnosticsystemmirtazapine
QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

…f escalating mental health crises with substance use; importance of comprehensive follow-up after acute psychiatric presentations; risk assessment in the context of polysubstance use, alcohol, and prescription medicatio…

psychiatryemergency medicinecommunicationsystemmethamphetamine
VICmental health2025-12-11

Finding into death of Tania Louise De Jong

48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…

…th depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identified during initial as…

psychiatrygeneral practicesystemcommunicationmorphine
NSWprison2025-02-19

Inquest into the death of Daniel Munro Lewis Turnbull

35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…

Daniel Turnbull, aged 35, died in custody from hyponatraemia secondary to psychogenic polydipsia whilst in a 24-hour surveillance cell at Bathurst Correctional Centre. He had a long history of schizophrenia managed with …

psychiatryintensive carecommunicationsystemolanzapine
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

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