Coronial

95 results for adolescent suicide

NSWcommunity2022-10-07

Inquest into the death of Charli Powell

17y · Female·Hanging

Charli Powell, 17, died by hanging at Freebody Oval on 11 February 2019 during an abusive relationship with Rohan Rosewarne. The coroner found her death was intentionally self-inflicted but occurred in the context of sig…

pathologypsychiatrysystemcommunicationcannabis
SAhospital2018-03-05

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…

Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumoni…

psychiatrypsychologydiagnosticcommunicationquetiapine
NT2016-06-08

Inquest into the death of Madeline Downman

17y · Female·self-inflicted hanging

…f unstable placements (26 total) and fragmented mental health care. Despite evidence of mood disorder and suicide risk, she disengaged from psychological counselling in January 2014 and refused further treatment. Key fa…

psychiatrypaediatricscommunicationsystemmarijuana
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

…d included an unsuitable co-resident. Key clinical failures included: insufficient recognition of chronic suicide risk, poor medication compliance without enforcement mechanisms, missed opportunities for crisis interven…

psychiatryemergency medicinediagnosticcommunicationcitalopram
QLDhospital2024-03-07

KLUMPER Joshua William

17y · Male·Hanging

…. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and self-harm. Critical clinical lessons include: the ED presentation on 2 September 2017 for c…

psychiatryemergency medicinecommunicationsystemcannabis
VIChospital2022-10-10

Finding into death of Oliver Vincent Paul Cronin

13y · Male·Hanging

…e. Emergency services resuscitated him but he died in ICU. The coroner found Oliver likely did not intend suicide but acted impulsively without understanding consequences. Key clinical lessons: gaming disorder is not ye…

psychiatrypsychologydiagnosticsystem
QLD2021-05-24

Ahquee, Dylon James

19y · Male·Hanging

…a juvenile, no Self-Harm Episode History flag was raised at adult prison intake, and he was not placed in suicide-resistant cells as recommended. Assessment Services follow-up on reported low mood in early December was …

correctional healthpsychologydiagnosticsystem
VIC2015-10-05

Finding into death of Catherine Jane Bernard

17y · Female·multiple injuries due to impact by train

…self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clinical failures included: (1) Monash Health's failure to report h…

emergency medicinepsychiatrycommunicationsystemtemazepam
NSW2022-12-15

Inquest into the death of YAKAMURRO - Findings

15y · Male·Neck compression due to hanging

…itutional failures isolated him from family while he struggled with severe behavioural dysregulation. The suicide was impulsive but preceded by systemic child protection failures. The coroner made five recommendations a…

systemcommunication
VICmental health2012-04-30

Finding into death of Travis Andrew McNees

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

Travis McNees, 18-year-old male, died by suicide on 4 October 2010 after absconding from Upton House psychiatric unit. He presented to ED on 29 September …

psychiatryemergency medicinecommunicationsystemparacetamol
VIChome2012-07-18

Finding into death of Joshua Meloury_Kaup

15y · Male·Mixed drug toxicity (morphine, 7-aminoclonazepam, fluoxetine, sertraline)

…hat night and on 14 May 2010 was found deceased. The coroner found no evidence of deliberate self-harm or suicide risk assessment failures. Key clinical lessons include: ensuring safe storage of potentially dangerous me…

paediatricspsychiatrysystemcommunicationmorphine
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

… health program (MHHITH) on 3 April 2019. He presented with depression, cannabis withdrawal, and multiple suicide attempts including a hanging attempt with velcro straps on 2 April. The coroner found he should never hav…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
NSWhome2014-08-13

Inquest into the death of Sean Leigh MacWilliam

16y · Male·asphyxia due to hanging, self-inflicted, with aspiration of gastric contents as …

Sean MacWilliam, 16 years old, died by asphyxia due to hanging on 24 March 2011. He had been admitted involuntarily to an adult mental health facility (Chisholm Ross Centre) following a mental health crisis on 15 March 2…

psychiatryemergency medicinecommunicationsystemfluoxetine
QLDhome

Naidu, Alvin

15y · Male·Hypoxic ischaemic brain injury, due to hanging

A 15-year-old boy died from hypoxic-ischaemic brain injury following a hanging attempt on 10 November 2004. The death occurred hours after his parents were informed by the school that he had been absent for seven consecu…

systemcommunicationvibra-tabs
VIChospital2019-02-05

Finding into death of Eliza Gill

18y · Female·Colchicine toxicity

An 18-year-old female died from colchicine toxicity after intentional overdose of her father's medications during a mental health crisis. She ingested approximately 10-15g of colchicine (dose 0.25mg/kg), below the guidel…

emergency medicineintensive carediagnosticsystemcolchicine
SA2019-11-14

Coroner's Finding: SINGH Heidi Eileen Roseanne

14y · Female·electrocution

…ergency care placement with rotating commercial carers. The coroner found her death was misadventure, not suicide. Key lessons: (1) Emergency/rotational care was inadequate for her complex needs; (2) CAMHS social worker…

paediatricspsychiatrysystemcommunicationquetiapine
SAhospital2008-01-02

Coroner's Finding: WOOD Jacqueline Moyra

17y · Female·raised intracranial pressure due to hepatic encephalopathy related cerebral oede…

Jacqueline Wood, aged 17, died from hepatic encephalopathy-related cerebral oedema following fulminant liver failure caused by paracetamol overdose. She ingested approximately 90 paracetamol tablets on 3 June 2002 but di…

paediatricsintensive carediagnosticparacetamol
NSWmental health2017-06-09

Inquest into the death of Ahlia RAFTERY

18y · Female·neck compression due to hanging

…nadequate communication of previous self-harm attempts during handovers, inappropriate downgrading of her suicide risk status despite clear high-risk indicators, ineffective observations during critical periods, and an …

psychiatrydiagnosticcommunicationfluoxetine
WAhome2005-12

Inquest into the Death of Jake Willem Dunne-Heynis

15y · Male·Ligature Compression of the Neck (Hanging)

…Heynis, a 15-year-old Year 11 student at Exmouth District High School in rural Western Australia, died by suicide on 23 June 2004, two days after hanging himself at home. Jake had motor coordination difficulties attribu…

communicationsystem
VICcommunity2023-04-19

Finding into death of J L

15y · Female·Hanging

A 15-year-old girl with major depressive disorder and bulimia nervosa died by suicide in June 2019. She had received treatment from a private psychologist from 2017-2018 within the constraint…

psychologygeneral practicecommunicationsystem

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