Coronial

96 results for previous suicide attempt

VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

… He had been discharged from psychiatric inpatient care on 1 February 2020 after a 14-day admission for a previous suicide attempt, placed on a Temporary Treatment Order with long-acting injectable antipsychotic medicati…

psychiatryemergency medicinecommunicationdelayrisperidone
WA2021-12-22

Inquest into the Death of Brett Ashley DUTURBURE

29y · Male·ligature compression of the neck (hanging)

Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures i…

correctional healthpsychiatrysystemcommunication
VICmental health2022-12-13

Finding into death of Jamie Andrew Kowalewsky

27y · Male·Global cerebral ischaemic injury in the setting of hanging

…old with long-standing mental health issues including depression, substance abuse (ICE and cannabis), and previous suicide attempt, was voluntarily admitted to a low dependency psychiatric unit on 24 April 2018. Over fou…

psychiatryintensive carecommunicationlorazepam
NT2008-10-10

Inquest into the death of Rebecka Hans

18y · Female·Gunshot wound to the head

… Hans, a 18-year-old woman, died from a self-inflicted gunshot wound to the head while police negotiators attempted to engage her at her Darwin River residence. She had called police early on 24 October 2007 expressing …

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), die…

psychiatrypsychologycommunicationsystemolanzapine
WA2000-02-11

Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

…ng Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previous suicide attempts, and was on psychotropic medication (Stelazine, Zoloft). Hayes was assessed as "at risk"…

psychiatrycorrectional healthsystemcommunicationstelazine
VIChospital2022-09-07

Finding into death of Mr AB

17y · Male·Hypoxic ischaemic encephalopathy due to hanging

…tigue, depression, anxiety, and gender dysphoria. Critical clinical lessons include: (1) recognition that suicide can be impulsive without preceding warning signs; (2) importance of coordinated care between mental healt…

psychiatryemergency medicinesystemcommunicationquetiapine
VIChome2019

Finding into death of Rachel Naomi Mihail

36y · Female·Nicotine toxicity

…ing mental health triage expressing suicidal intent. The clinical lessons relate to the response to acute suicide risk. At 1:10am, Ms Mihail disclosed to mental health clinician Rachel Finch that she had researched suic…

psychiatrygeneral practicecommunicationsystemnicotine
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

Gina Valera, a 49-year-old woman with a history of depression and three prior suicide attempts, died by hanging in Brisbane Women's Correctional Centre nine days after admission on remand for…

psychiatrycorrectional healthcommunicationsystemmirtazapine
VIChome2024-05-20

Finding into death of Gwyn Pugh

63y · Male·Incised injuries to the neck and upper limbs

Gwyn Pugh, a 63-year-old man with longstanding bipolar affective disorder, died by suicide on 26 October 2022. He had been hospitalized for depression in April-May 2022 and received electroconvuls…

psychiatrygeneral practicecommunicationsystemmirtazapine
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

…on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days earlier following workplace stress, shoulder injury, loss…

psychiatryemergency medicinediagnosticcommunicationcitalopram
VIChome2017-04-19

Finding into death of Lauren Pilkington

20y · Female·Asphyxia secondary to inhalation of helium

…-year-old postgraduate student, died by asphyxia from helium inhalation. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission at Delmont Private Hosp…

psychiatrygeneral practicesystemdelayfluoxetine
SAhome2001-07-16

Coroner's Finding: BRADY Mary

64y · Female·Haemorrhagic bronchopneumonia complicating doxepin overdosage

A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertrali…

general practicepsychiatrycommunicationmedicationdoxepin
VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

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

…ombined with alcohol intoxication and temporal proximity to the meeting, these factors contributed to her suicide. The coroner emphasised that BPD causes negative fixation, emotional dysregulation, and distorted percept…

psychiatrypsychologycommunicationsystemalcohol
SAmental health2000-12-12

Coroner's Finding: FELSTEAD Christopher John

33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes

A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He …

psychiatryemergency medicinediagnosticcommunicationcarboxyhaemoglobin
VICmental health2018-03-13

Finding into death of Elizabeth Anne Palmer

39y · Female·Hypovolaemic shock due to incised injury to the wrist

A 39-year-old woman with a history of mental health issues and previous suicide attempts was admitted to a high-dependency psychiatric unit following a suicide attempt involving…

psychiatryemergency medicineproceduralcommunication
VIChospital2014-05-14

Finding into death of Palma Castro

26y · Female·compression of the neck consequent upon hanging

…r two Emergency Department presentations within 5 hours on 17-18 February 2011. She presented following a suicide attempt with overdose and was discharged to family care without admission despite clear suicidality indic…

psychiatryemergency medicinecommunicationdocumentationalprazolam
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)

Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckle…

general practiceemergency medicinediagnosticcommunicationcitalopram
VICmental health2015-05-07

Finding into death of Narelle Ena Clancy

49y · Female·Hanging

… and died by hanging. She had a long history of depression and suicidal ideation following her daughter's suicide in 1999. While the decision to invoke involuntary status was based on sound clinical reasoning, critical …

psychiatrycommunicationsystemolanzapine
WA2020-02-05

Inquest into the Death of Tania Marie HODGKINSON

48y · Female·Ligature compression of the neck (hanging)

Tania Marie Hodgkinson, a 48-year-old Aboriginal woman, died by suicide via ligature compression while remanded at Bandyup Women's Prison on 23 March 2017. She had been admitted…

psychiatrypsychologycommunicationsystemheroin

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