Coronial

92 results for acute suicidal behaviour

NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

… Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered with antidepressants and l…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

…uma-informed or domestic and family violence lens. Despite repeated reports of physical and sexual abuse, suicidal ideation, self-harm, and escalating behaviours, CJ's needs remained unaddressed. Services focused on the …

paediatricspsychiatrydiagnosticcommunicationcannabis
QLDhospital2016-11-23

SPB - Non-inquest findings

36y · Male·hanging

…th 15-year history of paranoid schizophrenia and polysubstance abuse presented to hospital after violent behaviour toward his father while intoxicated. Despite police concerns, family requests for admission, and his tre…

psychiatryemergency medicinediagnosticcommunicationdiazepam
NThome2009-09-28

Inquest into the death of Danny Borrak Gumana

19y · Male·Intentional self-inflicted hanging

…tside a nightclub. He had previously threatened suicide twice in recent weeks while intoxicated, and his behaviour was increasingly concerning (not attending work, increased drinking). Police conveyed him home consensua…

psychiatrytoxicologyalcohol
SA2019-12-20

Coroner's Finding: MORGAN Martina

60y · Female·neck compression by ligature strangulation

…d have been classified as 'high need' rather than 'medium risk' based on her gross intoxication, reported suicidal history, PTSD diagnosis, and assertion of recent overdose. Mandatory 15-minute observations and CCTV moni…

diagnosticcommunicationalcohol
QLD2007-03-01

McGeary, Corey Allan

20y · Male·Self-inflicted hanging

Corey McGeary, a 20-year-old remand prisoner with chronic risk factors for self-harm (history of suicide attempts, schizophrenia, personality disorder, severe childhood abuse, mild intellectual disability), died by hangi…

psychiatrypsychologycommunicationsystemolanzapine
VIC2011-11-23

Finding into death of Tyler Cassidy

15y · Male·Gunshot wound to the chest

Tyler Cassidy, a 15-year-old boy, was fatally shot by Victoria Police on 11 December 2008 during a mental health crisis. He had stolen two large kitchen knives from Kmart and made threatening statements, explicitly deman…

emergency medicinecorrectional healthcommunicationsystemalcohol
SAhospital2019-03-25

Coroner's Finding: NICHOLSON James

65y · Male·hypoxic ischaemic encephalopathy complicating hanging

…to psychosis, depression, and paranoid delusions as the dose was reduced. On 14 August, after concerning behaviour and suicidal statements at home, he was admitted to hospital where Emergency Department physician Dr H. …

oncologypsychiatrydiagnosticcommunicationdexamethasone
TAShome2021-12-03

Coroner's Finding: Summers, Damian

42y · Male·hanging, an action taken by himself with the intention of ending his life

A 42-year-old man with acute psychosis was hospitalised for 26 days and discharged from a psychiatric facility to an isolated rural isl…

psychiatrygeneral practicecommunicationsystemolanzapine
SAhospital2000-11-20

Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
VIC2012-09-21

Timothycaseypart1 127708

29y · Male·hanging

…gistrar Dr S T urgently requested psychiatric consultant Dr A W review Casey for possible admission to the Acute Assessment Unit, but Dr A W never saw him. Without proper psychiatric review, Casey's suicide risk was dow…

psychiatrycorrectional healthdiagnosticcommunicationheroin
NTcommunity2009-10-19

Inquest into the death of Clifton Wayne Pamkal

22y · Male·Intentional self-inflicted gunshot wound to the head

A 22-year-old Aboriginal man died by self-inflicted gunshot wound while evading police custody. He had been arrested for breach of bail (living near a 15-year-old girl with whom he had an underage sexual relationship). H…

psychiatryemergency medicine
NSWmental health2017-06-09

Inquest into the death of Ahlia RAFTERY

18y · Female·neck compression due to hanging

…-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate communication of previous self-harm …

psychiatrydiagnosticcommunicationfluoxetine
VICcommunity2014-04-24

Finding into death of Mark Bethell

32y · Male·Valproic Acid Overdose

Mark Bethell, a 32-year-old with bipolar affective disorder and borderline personality disorder, died from valproic acid overdose at a crisis accommodation facility. He was admitted to John Cade Psychiatric Unit followin…

psychiatryemergency medicinediagnosticcommunicationsodium valproate
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding as…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
WAhospital2016-03-24

Inquest into the Death of Jesse Richard DELLAR

17y · Male·ligature compression of the neck (hanging)

Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentionally overdosing on his ADHD med…

psychiatrygeneral practicediagnosticsystematomoxetine
VIChome2023-07-28

Finding into death of Jackson Desmond David Stawicki

24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm

…s (4-5 September 2020) following police apprehension under the Mental Health Act for erratic, aggressive behaviour. Each time, ED and mental health assessments determined he did not meet criteria for compulsory treatmen…

emergency medicinepsychiatrycommunicationsystemflualprazolam
QLDhospital2008-12-15

Harris, Robert

60y · Male·asphyxia sequential to hanging due to depression

Robert Harris, a 60-year-old man with depression, made two suicide attempts within 24 hours. After the first attempt on 27 June 2006, he was discharged from Cairns Base Hospital Emergency Department with a plan to attend…

psychiatryemergency medicinecommunicationdiagnosticfluvoxamine
SA2006-04-28

Coroner's Finding: WALKER Darryl Kym

31y · Male·hanging (self-inflicted)

… transferred to an isolated management unit (Unit 7) on 1 June after displaying agitation and aggressive behaviour during a blood sugar check. Nursing staff recognised his deteriorating mental state and arranged urgent …

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

…ns to emergency services and mental health services from March to July 2021 with deliberate self-harm and suicidal ideation, all in context of intoxication and relationship breakdown. While clinicians offered appropriate…

psychiatrygeneral practicesystemcommunicationalcohol

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