Coronial

88 results for acute psychotic illness

NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurre…

general practicepsychiatrycommunicationsystemtriflouperazine
VICmental health2012-04-03

Finding into death of Miles David Colman

21y · Male·Head injury sustained in fall from height

…bservations were all appropriate and reasonable given his clinical improvement. Suicide risk prediction in acute psychosis remains challenging; despite family support and appropriate care, the impulsive fatal act could …

psychiatryintensive carerisperidone
NSW2025-01-16

Inquest into the death of Tammy Michelle Shipley

47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffecti…

…tal health history in custody records despite having multiple recent interactions with her showing mental illness; the NSWPF Facts Sheet falsely stated 'Police not aware of any drug or mental health issues'; the police …

psychiatryemergency medicinediagnosticcommunicationbuprenorphine
WA2004-03-02

Inquest into the Death of Natasha Leanne Quartermaine

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

… died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, personality disorder, and poly-drug abuse. On the morning of her death, she expressed suicidal ideation …

psychiatrygeneral practicecommunicationsystemzuclopenthixol
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
VIChome2026-01-13

Finding into death of Filippo Pignataro

52y · Male·Pulmonary thromboembolism

…e. Clinicians should consider VTE risk stratification in immobilised patients recovering from respiratory illness, particularly those with reduced mobility or comorbidities, and document risk-benefit discussions when pa…

general practiceemergency medicineamoxicillin
SAhospital2026-05-28

Coroner's Finding: Sargeant, Gary Dale

36y · Male·Drowning

…oyal 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 psychologist's failure to read urgen…

general medicinepsychiatrydiagnosticprocedural
NTmental health2002-03-12

Inquest into the death of Luke Peter Littlewood

21y · Male·multiple injuries from fall from water tower

A 21-year-old man with acute psychosis was admitted involuntarily to a psychiatric ward after being found climbing a power pole. After …

psychiatrycommunicationproceduralolanzapine
QLDhome2015-03-19

Press, Connon Kenneth

33y · Male·Gunshot wound to the head

… died from a self-inflicted gunshot wound to the head. He had been prescribed risperidone and prozac for psychotic symptoms and was experiencing significant paranoid delusions on the morning of his death. Post-mortem to…

psychiatryforensic medicinemethamphetamine
QLDcommunity2025-05-02

Non-inquest findings into the death of Mr T.

49y · Male·undetermined

…ne became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police attempted to locate him for involuntary admission. Despite …

psychiatrysystemcommunicationclozapine
ACThospital2014-06-02

Findings Into The Death Of Mijo Galinec

69y · Male·asphyxia by hanging

A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…

psychiatryemergency medicinecommunicationsystemolanzapine
WAmental health2015-11-30

Inquest into the Death of Frances May COOPER

48y · Female·Head injury

Frances May Cooper, a 48-year-old woman with chronic paranoid schizophrenia, died from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Re…

psychiatryemergency medicineproceduralsystemrisperidone
WAhome2005-07

Inquest into the Death of taylor

29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath

Louis Bernard Taylor, a 29-year-old Aboriginal male, died from a penetrating wound to the neck inflicted by himself on 23 August 2002. Recently released from prison after four years incarceration, Louis was attempting to…

psychiatrygeneral practicecannabis
VIChome2021-12-06

Finding into death of Daniel Charles Richards

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

…h crisis responses; (2) the importance of assuming underlying cardiovascular disease in those with mental illness; (3) de-escalation and communication training for police (PRIME training); and (4) paramedic-led emergenc…

psychiatryemergency medicinesystemcommunication
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

…died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic injections and antidepressants. Cri…

psychiatrygeneral practicesystemdelaypaliperidone
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

…h nurse specialist on 24 April 2008 who noted fleeting suicidal thoughts but found him future-oriented, no acute risk was identified. Following lockdown on 27 April, Brennan obtained razor blades and cut his forearms fa…

psychiatrycorrectional healthsystemdelaylithium
WAhospital2013-02-11

Inquest into the Death of Carroll

21y · Male·Acute hypoxic ischaemic encephalopathy and pneumonia in a man with recent trauma…

Peter Martin Carroll, age 21, died on 8 June 2007 in the ICU at Royal Perth Hospital from acute hypoxic ischaemic encephalopathy and pneumonia following oxycodone overdose. He had been discharged that d…

emergency medicineorthopaedic surgerycommunicationsystemoxycodone
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

Peter Cornish, a 43-year-old man with a 17-year history of bipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, mul…

psychiatryemergency medicinediagnosticsystemcannabis
WAcommunity2017-09-06

Inquest into the Death of Mamadou Hady DIALLO

39y · Male·multiple injuries from motor vehicle collision

…der died by suicide in a head-on motor vehicle collision. He had been appropriately managed on depot antipsychotic medication with generally good psychiatric care. However, a critical gap occurred when his GP (Dr C.), l…

psychiatrygeneral practicecommunicationdiagnosticrisperidone
NT2023-02-24

Inquest into the death of Bernard Hector

31y · Male·self-inflicted hanging

…aced 'at risk' following his court appearance. A mental health assessment on 14 July 2021 found no mental illness or acute suicide risk, leading to removal from 'at risk' status and closure of forensic mental health fol…

psychiatrycorrectional healthcommunicationsystem

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