Coronial

273 results for acute mental illness

WAhome2021-08-10

Inquest into the Death of Scott William MARTIN

40y · Male·Penetrating wounds to the chest

…is partner. Key clinical lessons: police officers failed to adequately recognise and act on clear signs of acute mental illness (delusions, hallucinations, disordered thought, impulsivity, unregulated emotions). They di…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
SAhospital2017-11-17

Coroner's Finding: CAMERON George William

76y · Male·pneumonia and exacerbation of chronic obstructive airway disease

…eumonia and exacerbation of chronic obstructive airway disease at Noarlunga Hospital. He was admitted with acute alcohol withdrawal, confusion, and respiratory symptoms. A Level 1 inpatient treatment order was appropria…

psychiatrygeneral medicinesalbutamol
TAScommunity2019-08-13

Coroner's Finding: Jeffrey, Angela Joy

53y · Female·Unable to determine; circumstances suggest death by suicide but body never recov…

Angela Joy Jeffrey, a 53-year-old woman with a long history of depression managed with antidepressants and psychiatric care, disappeared on 1 June 2016 from Bakers Beach, Tasmania. She had experienced a significant mood …

psychiatrygeneral practiceantidepressant medication
SAhospital2018-02-29

Coroner's Finding: EVANS Wendy Marion

76y · Female·end-stage liver failure with encephalopathy due to hepatic cirrhosis

…ged 76, died from end-stage liver failure with encephalopathy due to hepatic cirrhosis. She presented with acute psychosis in February 2015 and was found to have extensive cerebrovascular disease, severe cerebellar atax…

psychiatryhepatology
WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

…h active TB and received a four-drug treatment regime. Readmitted in June 2024 with multi-organ sepsis and acute kidney injury, he required intensive care. Despite comprehensive care from multiple specialist teams (Resp…

respiratory medicineinfectious diseasesproceduralsystem
VIChome2014-03-06

Finding into death of Samantha Jane Fowler

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

…hildren (Samantha 18, Melanie 13, Matthew 11) and herself by stabbing and fire on 9 January 2011 during an acute psychotic episode. Critical system failures included: no confirmation that Ms Fowler engaged with her GP a…

psychiatrypaediatricscommunicationsystemrisperidone
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

Philip Sulley, 58, died of coronary artery arteriosclerosis on 27 April 2020 at Bentley Mental Health Unit. He presented to Royal Perth Hospital emergency department on 19 April 2020 with psychotic beh…

psychiatryemergency medicinecommunicationolanzapine
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

…m reporting CTH's hallucinations, paranoia and drug use, paramedics and police assessed him as not meeting Mental Health Act thresholds for involuntary admission. The coroner identified system failures in Child Protectio…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
NSWhospital2017-04-19

Inquest into the death of Heidi COX

58y · Female·consequences of acute subdural haemorrhage

Heidi Cox, 58, died from acute subdural haemorrhage after suffering interpersonal violence, likely at the hands of her long-term partner …

emergency medicineintensive carequetiapine
TAScommunity2020-11-23

Coroner's Finding: Golding, Laura Rebecca

51y · Female·drowning

…the police response was timely and appropriate. Clinical lessons include the importance of engagement with mental health treatment, earlier recognition of escalating psychotic symptoms, and the challenges of managing pat…

psychiatrygeneral practicesystemdelay
VIChospital2021-08-16

Finding into death of XA

39y · Male·Complications arising from widely disseminated primary pulmonary small cell carc…

… complications of widely disseminated small cell lung cancer with hepatitis C cirrhosis. He presented with acute psychosis and catatonia in December 2018, receiving appropriate psychiatric care including ECT. During sub…

psychiatryoncologyolanzapine
VIC2015-12-18

Finding into death of Odisseas Vekiaris

29y · Male·Unascertained causes on a background of agitated delirium state

A 29-year-old man with a 12-year history of mental illness died in police custody during transport to a police station. He had stopped taking his antipsychot…

general practicepsychiatrycommunicationsystemrisperidone
SA2015-11-16

Coroner's Finding: TROTTA Pellegrino

53y · Male·smoke inhalation and effects of heat from motor vehicle fire

…urveillance, with evidence of methamphetamine use. He had not sought medical evaluation despite concerning mental health symptoms. On the day of his death, he engaged in erratic and dangerous public behaviour before brea…

methamphetamine
VIC2021-05-07

Finding into death of Joanne Finch

42y · Female·Neck compression due to self-suspension

…n her cell at Dame Phyllis Frost Centre on 24 July 2018. She had chronic suicidal ideation with periods of acute risk, was under regular psychiatric review, and was managed with appropriate risk ratings (S2 at time of d…

psychiatrypsychologyolanzapine
NSWcommunity2024-04-18

Inquest into the death of Baby Q

0y · Female·unascertained

…mily, transient and homeless, were known to child protection and police in NSW and Queensland with complex mental health issues. Critical failures included Queensland DCSSDS inadequately assessing an August 2018 notifica…

paediatricspsychiatrysystemcommunication
WAcommunity2017-09-06

Inquest into the Death of James Michael Chee Ming YUNG

42y · Male·Multiple injuries sustained in motor vehicle crash

… crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern of acute relapses requiring repeated hospitalisations. In late May 2015, despite signs of relapse and non-complianc…

psychiatryemergency medicinedelaysystempaliperidone depot
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

…ication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The Maryborough Mental Health Unit discharged him twice in late July 2003 despite clear manic symptoms and documented history, ci…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
VIChome2014-02-12

Finding into death of Sibel Yilmaz

24y · Female·hanging

…ty counsellors and a psychologist between 2008-2009, was prescribed sertraline, and was assessed as not at acute risk but vulnerable. The critical failure was her family's ignorance of her mental illness; she did not co…

psychologypsychiatrycommunicationsertraline
SAhospital2011-12-02

Coroner's Finding: BINCH Joyce

82y · Female·acute pyelonephritis complicating base of bladder malignancy

Joyce Binch, 82, died of acute pyelonephritis from bladder malignancy while detained under mental health legislation. She was admitted wi…

psychiatrygeneral medicinerisperidone
VIChospital2014-02-10

Finding into death of Glenn Stewart Hayes

36y · Male·Hypoxic/ischaemic encephalopathy and hanging

… use. He explicitly stated suicidal intent to multiple contacts. Clinical learning includes recognition of acute mental health crisis in patients with polysubstance abuse, untreated depression, and multiple stressors. E…

intensive careemergency medicinediagnosticsystemmethamphetamine
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