Coronial

746 results for psychiatric treatment

VIChome2014-03-06

Finding into death of Matthew Patrick James Maher

36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …

Kylie Fowler, a 36-year-old woman with a 18-year history of schizophrenia requiring five involuntary psychiatric admissions, killed herself and her three children (Melanie, 13; Matthew, 11; Samantha, 18) on 9 January…

psychiatrypaediatricscommunicationsystemrisperidone
NSWhospital2025-08-14

Inquest into the death of Wilfred Whippy Williams

45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia

…the doctor been informed promptly, skilled engagement could likely have brought him back for life-saving treatment.

emergency medicineendocrinologycommunicationdiagnosticmetformin
QLD2019-05-08

Malone, Terrence Michael

54y · Male·incised wound to the neck

…ents in hospital; (2) integrated assessment of mental health and substance use is essential—his separate treatment as siloed issues in hospital and prison contributed to inadequate care; (3) early imprisonment is highes…

psychiatryemergency medicinediagnosticcommunicationalcohol
SA2006-05-22

Coroner's Finding: GEORGE Patricia Nina

81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…

Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive heart failure. A critical ambulance transfer delay …

psychiatryemergency medicinecommunicationsystemsalbutamol
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

… mental health screening tools for cancer patients; and that metoclopramide carries rare but recognised psychiatric risks that warrant explicit risk-benefit consideration in patients with depression, though no causal li…

psychiatryhaematologycommunicationdelaymetoclopramide
VIChome2015-11-27

Finding into death of Sherry Ann Robinson

38y · Female·multiple stab injuries to the chest and abdomen

A 38-year-old woman was fatally stabbed by her former partner, Bradley Carolus, in May 2010. Three days before the homicide, Carolus had been apprehended by police under mental health legislation following a volatile epi…

psychiatryemergency medicinecommunicationsystemquetiapine
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…

emergency medicinepsychiatrycommunicationdelayolanzapine
NSW2017-11-06

Inquest into the death of Edward Haenga

37y · Male·cardiac arrhythmia

…rmacy, maintain mandatory documentation of ceased medications, and ensure physical investigations guide psychiatric treatment decisions.

psychiatrygeneral practicemedicationproceduralescitalopram
ACT1997

Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

21y · Male·Suffocation from hanging

…he critical period when Camden died (likely around 4:30 AM). The coroner found that the quality of care, treatment and supervision by Mr Black (supervisor), Mr Kelly, Mr Gordon, and Mr Curbishley all contributed to the …

psychiatrypsychologyproceduralsystem
VIChome2021-12-06

Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …

psychiatryemergency medicinesystemcommunication
WAhospital2004-06-17

Inquest into the Death of Edmiston

41y · Female·Peritonitis following surgical procedure to the urinary bladder, due to infected…

…ohol consumption. The coroner found the death entirely preventable with competent supervision and timely treatment, and referred all three doctors to the Medical Board.

urologygeneral surgerydiagnosticmedicationamoxicillin
NSWhospital2023-07-21

Inquest into the death of Ziad Hamawy

51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …

Ziad Hamawy, a 51-year-old man with chronic schizophrenia and polysubstance use disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019…

psychiatryemergency medicinediagnosticcommunicationheroin
NThome2026-06-19

Inquest into the death of RL

17y · Male·Suicide by self-inflicted hanging

…. Critical clinical lessons emerged: failure to inform his mother about mental health deterioration and psychiatric hospitalizations; poor communication between school and mental health services despite recognizing high…

psychiatrypsychologycommunicationdiagnostic
VIC2024-05-14

Finding into death of Brian Richard Pope

40y · Male·compression of the neck due to hanging

…ks were discontinued after initial assessments despite recent suicidal history and ongoing mental health treatment. The coroner found no adverse comment appropriate but identified system failures in information gatherin…

psychiatrycorrectional healthcommunicationsystemmirtazapine
QLDhome2019-11-06

Follent, Mitchell James - Non-inquest findings

22y · Male·Multiple injuries from fall from height

Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired…

psychiatryneurologydiagnosticcommunicationolanzapine
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …

psychiatrypsychologysystemcommunicationpseudoephedrine
NSWmental health2025-08-13

Inquest into the death of Allyson Bailey

42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…

Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…

emergency medicineintensive carediagnosticcommunicationbaclofen
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

…s (obesity, respiratory infection, diabetes), presented to Logan Hospital after police noted concerning psychiatric behaviour. He was appropriately assessed in the Short Stay Unit, where blood gas analysis revealed crit…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…

general medicinepsychiatrydiagnosticprocedural
QLD2011-12-09

Inglis, Tracey Lee

37y · Female·exsanguination from incised wounds to right wrist and elbow

Tracey Inglis, a 37-year-old woman with chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial R…

psychiatrygeneral practicediagnosticcommunicationparacetamol/codeine

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