Coronial

78 results for childhood trauma

VIChome2015-04-13

Finding into death of Athiel Deng

59y · Female·head injury

Ms Athiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in…

psychiatryemergency medicinesystemdelaycannabis
VIChome2022-08-30

Finding into death of Boe Luke Memery

24y · Male·Neck compression in the circumstances of hanging

Boe Luke Memery, a 24-year-old Aboriginal man, died by hanging on 19 May 2019 following a relationship breakdown. He had a history of depression, self-harm, and previous suicide attempts. In the weeks before his death, h…

psychiatrygeneral practicedocumentationcommunicationvenlafaxine
NSWcommunity2024-02-20

Inquest into the death of Jasmynd Gibbs

33y · Male·Complications of methylamphetamine use

… two months after release. He had complex needs including mental health disorders, cognitive disability, childhood trauma, and substance use issues. Despite a supportive mother initially, Jazzy relocated to unsuitable m…

correctional healthpsychiatrysystemcommunicationmethamphetamine
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

…ug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relationship breakdown. She presented to healthcare se…

general practicepsychiatrydiagnosticcommunicationmorphine
SAhospital2008-01-02

Coroner's Finding: WOOD Jacqueline Moyra

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

…ations of sexual abuse she had made, combined with her intellectual disability, epilepsy history, and past trauma. No criticism was directed at healthcare workers; the death could not have been predicted despite availabl…

paediatricsintensive carediagnosticparacetamol
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
VIC2022-07-28

Finding into death of Master S

17y · Male·Unascertained in the setting of volatile substance abuse

Master S, a 17-year-old Yorta Yorta young man, died on 3 July 2017 at the Bert Williams Hostel from a cause unascertained in the setting of volatile substance abuse (chroming Rexona deodorant). He had a history of exposu…

paediatricspsychiatrycommunicationsystemrexona deodorant
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

A 3-year-old girl was killed by her mother, who was experiencing a severe psychotic episode with suicidal and homicidal ideation. The mother had a history of Brief Psychotic Disorder (diagnosed 2015), was on olanzapine 1…

psychiatrygeneral practicecommunicationsystemolanzapine
WAhospital2024-05-23

Inquest into the Death of Baby BE (Name Subject to Suppression Order)

<1y · Female·brain death complicating head and neck injury

A five-month-old girl died from catastrophic brain injuries caused by violent shaking on 20 May 2019. Medical evidence established she was shaken by an adult on at least two occasions: once around 6 May 2019 (evidenced b…

paediatricsneonatologydiagnosticcommunicationmethamphetamine
WA2019-08-20

Inquest into the Death of Judy Sonia BOLTON

44y · Female·acute myocardial infarction due to coronary thrombosis

A 44-year-old Aboriginal woman died from acute myocardial infarction (heart attack) due to coronary thrombosis while in custody at Bandyup Women's Prison in Western Australia. She had multiple cardiovascular risk factors…

cardiologyemergency medicinediagnosticsystemmetoprolol
WAcustody2017-02-28

Inquest into the Death of Jayden Stafford BENNELL

20y · Male·ligature compression of the neck (hanging)

Jayden Stafford Bennell, a 20-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died by ligature compression of the neck (hanging) in a cleaning storeroom on 6 March 2013. He had a complex psychiatric h…

psychiatrycorrectional healthcommunicationsystemquetiapine
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
NSWcommunity2023-08-08

Inquest into the death of Simon Miles

42y · Male·heroin and methylamphetamine toxicity

Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…

addiction medicinepsychiatrysystemcommunicationheroin
WAcustody2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
NSWaged care2022-09-28

Inquest into the death of Kerry-Ellen (Nikki) Knight

44y · Female·Hanging

Kerry-Ellen Knight, aged 44, died by suicide in custody at Silverwater Women's Correctional Centre on 5 March 2021 after only 6 days in custody. She was in COVID-19 quarantine in an old-style cell with prominent hanging …

psychiatrycorrectional healthdiagnosticcommunication
VIChospital2025-01-10

Finding into death of William Thomas Gourley

39y · Male·Effects of fire (self-immolation)

William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 202…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

…atening to self-immolate due to distress about power cuts at his caravan park causing darkness (triggering trauma from childhood sexual abuse). Police transported him to Bairnsdale Hospital but failed to contact mental h…

emergency medicinepsychiatrycommunicationsystem
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …

paediatricspsychiatrycommunicationsystemvenlafaxine

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