15y · Female·neck compression due to hanging
Michaela Mundy, a 15-year-old with depression, was seen by CAMHS therapist Vina Hotich from July-November 2011, presenting with suicidal ideation, sel…
33y · Female·neck compression and hanging
Natalie was a 33-year-old transgender woman with a long history of mental health conditions including severe social anxiety, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17…
53y · Female·Hypoxic brain injury due to hanging
A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency…
46y · Female·hypoxic brain injury due to hanging
A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously …
Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…
An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged …
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
Hugh Lisle, a 24-year-old man with severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatri…
38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…
…e coroner found the use of force was justified and proportionate. Clinical lessons include: recognition of severe suicidality as a medical emergency warranting stronger mental health intervention; the risk that medicatio…
20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)
Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active…
48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…
…escribed food daily, but he failed to comply. Over the following four months, she lost 13.2 kg, developing severe malnutrition and infected bedsores (sepsis). A neurologist testified that proper feeding would have extend…
34y · Male·hypoxic encephalopathy following hanging
Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had…
49y · Male·hanging (suicide)
…discharge from Ward B8 (psychiatric short-stay unit) at Royal Adelaide Hospital. He had been admitted with severe depression and active suicidal ideation. The coroner found his discharge was premature and inappropriate. …
49y · Male·Hanging
A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepe…
Male·Myocardial failure resulting from excessive pulmonary blood flow and consequenti…
…ely 1 kilogram, died from myocardial failure secondary to excessive pulmonary blood flow in the context of severe congenital heart disease (pulmonary atresia with intact ventricular septum and right ventricular hypoplasi…
Male·Ashton Michael Sunfly: ligature compression of the neck (hanging); Mitchell Nana…
…ng. The coroner identified school truancy as an early warning indicator of life trajectory off-track and a major contributor to vulnerability. Key recommendations address mandatory volatile substance abuse treatment leg…
59y · Male·Gunshot wound of head
… police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP management for …
59y · Male·head injuries
…hile involuntarily detained at Nolan House mental health facility in April 2021. He developed sudden onset severe mental illness (anxiety disorder with depressive features, with possible psychotic depression) triggered b…
22y · Female·plastic bag asphyxia, possibly contributed to by neck compression
A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental…
34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…
Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide …
77y · Female·hypothermia from environmental cold exposure with contributing factors of advanc…
Mrs Janet Mackozdi, aged 77, died from hypothermia in an uninsulated shipping container at Mount Lloyd, Tasmania, on 23-24 July 2010. She had advanced Alzheimer's dementia and required 24-hour care. The coroner found her…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
…t orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found he should have been under continuous rather than close observa…
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