Coronial

654 results for mental health issues

VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

…was involved with multiple services including Child Protection, Youth Justice, and the Adolescent Forensic Health Service. Despite psychiatric assessments identifying depression, anger issues, and trauma, psychiatrists r…

psychiatrypsychologysystemdelay
NT2011-11-25

Inquest into the death of Bird

46y · Male·Acute hypoxic brain damage resulting from intentional self-inflicted hanging

… from acute hypoxic brain damage following self-inflicted hanging in custody. He had a history of physical health issues including HIV and mental health concerns including anger management difficulties. Despite appropria…

psychiatrypsychology
VIC2020-04-06

Finding into death of Darren Brandon

51y · Male·hypoxic-ischemic encephalopathy due to hanging

…om a 2003 motorcycle accident, depression, and history of suicide attempts. Critical information about his mental health and vulnerability was not communicated between the police custodial health service and prison recep…

psychiatryforensic medicinecommunicationsystemoxycodone
WA2023-08-23

Inquest into the Deaths of Adell Sherylee PARTRIDGE and Veronica Philomena LOCKYER

Female·unascertained

…remains a person of interest given documented severe domestic violence in their relationship, his volatile mental health history, and inconsistencies in his accounts. No charges were laid. The case demonstrates failures …

communicationsystem
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

…gh-risk circumstances including prior removal of the mother's first child, domestic violence, and parental mental health issues. Brighter Futures' practitioner, despite observing concerning signs of parental substance us…

paediatricspsychiatrydiagnosticcommunicationquetiapine
TAShome2022-01-05

Coroner's Finding: Hay, Geoffrey Robert

66y · Male·Unable to determine

… death. Mr Hay had discussed suicide prior to his disappearance and was experiencing hip pain and mobility issues but had not sought medical attention. The coroner made no adverse findings regarding healthcare providers …

VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

31y · Female·neck compression in the circumstances of hanging

…gh the coroner found that objectively, the managers' conduct was reasonable given they were unaware of her mental health history, subjectively Tessa's BPD caused her to catastrophise these workplace issues. Combined with…

psychiatrypsychologycommunicationsystemalcohol
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

…d that Senior Constable Hansen should have called the mother back for additional information. Key systemic issues identified: understaffing at Nepean PAC leading to unanswered phone calls, lack of centralised mental heal…

psychiatryforensic medicinecommunicationsystemdiazepam
ACT2023-10-04

In the matter of three deaths of AFP appointees in the Australian Capital TerritoryInquest into the Death of Richard RobertsInquest into the Death of Samantha BaglinInquest into the Death of Dominic Coleman

Unknown·Self-inflicted gunshot wound; suicide

…s: Richard Roberts (57, PSO), Samantha Baglin (44), and Dominic Coleman (52, ASO). All three had untreated mental health conditions and avoided disclosure through the required Change of Health Notification Form (COHNF). …

occupational and environmental healthpsychiatrysystemcommunication
WAcommunity2025-05-27

Inquest into the Suspected Death of George William LE VAUX

70y · Male·Unknown cause; presumed drowning but sudden medical event cannot be excluded

George William Le Vaux, a 70-year-old man with multiple chronic health conditions including severe headaches, back pain, fibromyalgia, and chronic fatigue syndrome, disappeared …

VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

…oxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental health issues following a 2012 motor vehicle accident (deliberate self-harm) resulting in chronic pain man…

general practiceforensic medicinecommunicationsystemoxycodone
VIC2021-03-18

Finding into death of Stanley Bruce Weaver

61y · Male·Hanging

…His wife had reported concerns about medication stockpiling and suicidal intent to police on 24 July 2019. Mental health assessment by Monash Health CAT Team on 25 July 2019 found no acute risk requiring involuntary trea…

psychiatrygeneral practicesystemdiazepam
WAhome2023-06-28

Inquest into the Death of Nicholas Arthur CRIPPS

47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…

…ty, hypertension, and cardiomegaly. He was subject to a Community Treatment Order and managed by community mental health services. His death was accidental rather than suicidal. While his treating team provided reasonabl…

psychiatrygeneral practicesystemmethamphetamine
NSWhospital2018-06-26

Finding into death of Luke John De Piazza

34y · Male·hanging

Luke De Piazza, a 34-year-old man with long-standing mental health issues, died by hanging on 3 March 2017. Six days prior, he had voluntarily discharged from a psych…

psychiatryemergency medicinesystemcommunicationolanzapine
NSWhome2022-10-07

Inquest into the death of Jasson Pearce

47y · Male·Gunshot wounds to the chest

…legislation. The coroner found the manner of death was lawful discharge of a firearm in execution of duty. Issues identified include: inadequate body-worn video capture due to early rollout stage; gaps in information ava…

alcohol
VICcommunity2011-05-16

Finding into death of Aaron

14y · Male·injuries sustained in fall from height

…ance misuse, poor school attendance, and homelessness. The coroner found that DHS failed to conduct proper mental health assessments despite documented self-harming behaviour and suicidal ideation expressed to friends. M…

paediatricspsychiatrydiagnosticsystem
WA2012-01-12

Inquest into the Death of Brennan

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

…the months before death, he became non-compliant with psychiatric medication despite treatment from prison health services. Although reviewed by a mental health nurse specialist on 24 April 2008 who noted fleeting suicid…

psychiatrycorrectional healthsystemdelaylithium
NSWcommunity2018-10-24

Inquest into the death of Michael Joyce

28y · Male·Multiple injuries sustained from fall from cliff

… Joyce, 28, died after stumbling and falling from a cliff at Dunningham Reserve, Coogee while experiencing mental disturbance. He had a history of insomnia-related mental health issues (previous psychosis, hospitalisatio…

emergency medicinepsychiatrytemazepam
SAhospital2020-11-02

Coroner's Finding: MILOCCHI Guiseppe

90y · Male·pneumonia leading to atrial fibrillation leading to myocardial infarction

…disease died from pneumonia leading to atrial fibrillation and myocardial infarction while on an inpatient mental health treatment order. He was admitted with hospital-acquired pneumonia and acute kidney injury following…

emergency medicinepsychiatryantibiotics
VIChome2012-12-12

Finding into death of B K

Female·Hanging

The deceased was a woman with a long history of heroin abuse, benzodiazepine misuse, and mental health issues including depression and psychotic behaviour. She received treatment for opiate dependence a…

addiction medicinepsychiatryheroin
134533

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.