Coronial

402 results for suicide risk high

TAScommunity2021-01-25

Coroner's Finding: Townsend, David Lester

69y · Male·Partial contact range gunshot wound of the head

…s treating psychiatrist and case manager, whom he blamed for the appointment. The coroner found he received high-quality mental health care and that his death could not have been reasonably prevented. No mandatory firear…

psychiatrygeneral practice
VICmental health2023-06-22

Finding into death of Catherine Ann Williamson

58y · Female·plastic bag asphyxia

…stic bag asphyxia at a private mental health facility. She had schizo-affective disorder and a history of suicide attempts. Despite returning from supervised leave on 10 September 2017, no physical search was performed.…

psychiatrysystemcommunication
VIChome2012-02-14

Finding into death of Edo Travaglia

54y · Male·Carbon monoxide poisoning

…s with profound disabilities, died of carbon monoxide poisoning along with his sons in an apparent murder-suicide. Despite significant improvement in his sons' care following a change to a new disability service provide…

psychiatrygeneral practicebenzodiazepines
VIChome2024-08-29

Finding into death of Natalie Wilson

33y · Female·neck compression and hanging

…, agoraphobia, borderline personality disorder and PTSD, with suicidal ideation since age 17 and multiple suicide attempts. She died by hanging on 2 September 2020 after being offered voluntary hospital admission for hi…

psychiatrypsychologysystemescitalopram
WAmental health2015-02-26

Inquest into the Death of Tracy Margaret MARSHALL

47y · Female·Ligature compression of the neck (suicide by hanging)

…ote location in Millstream National Park where she abandoned her damaged vehicle and subsequently died by suicide via ligature compression of the neck. Clinically, this case highlights the critical importance of risk as…

psychiatrysystemdelay
VIChospital2020-10-21

Finding into death of Anthony Lansell Churches

70y · Male·Cyanide Toxicity

… suicidal intent during custody assessment. In the ED, he was assessed as calm and cooperative, placed in a high-visibility cubicle without one-to-one observation, and absconded at 3:40pm during the busy afternoon shift …

emergency medicinepsychiatrycommunicationsystemcyanide
NTmental health2019-09-13

Inquest into the death of Daniel Alexander Bleaney

37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof

Daniel Bleaney, 37, experienced acute psychosis with command hallucinations while at sea and attempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, …

psychiatryemergency medicinesystemdiagnosticdiazepam
QLD2007-05-16

Davis, Jodie Maree

24y · Female·hypoxic brain damage due to cardiac arrest due to hanging

Jodie Maree Davis, aged 24, died by suicide in Townsville Correctional Centre in May 2002. She had a long history of self-harm dating from age 15, in…

psychiatrypsychologysystemcommunication
VICmental health2016

Finding into death of Rebecca Victoria Poke

29y · Female·global cerebral ischaemic injury in the setting of neck compression

Rebecca Poke, a 29-year-old woman with borderline personality disorder, died by suicide while an inpatient in Ward E of Casey Hospital on 2 September 2015. She had been admitted following a par…

psychiatryintensive caresystemvenlafaxine
QLDprison2021-11-23

Row Row, Frederick Arthur James

34y · Male·Neck compression by hanging

Frederick Row Row, a 34-year-old Aboriginal man, died by suicide in Capricornia Correctional Centre following a precipitous change in risk assessment from high to low in …

psychiatrypsychologydiagnosticcommunication
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

…atment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with referral to community mental heal…

psychiatryemergency medicinesystemdelaymirtazapine
NThome2008-08-26

Inquest into the death of Wayne Walker and Jacqueline Morrison

Male·Self-inflicted gunshot wound to the head (Walker); Homicidal cutthroat (Morrison…

…t a Katherine residence: Jacqueline Morrison (homicide by cutthroat on 9 February 2008) and Wayne Walker (suicide by self-inflicted gunshot on 13 February 2008). Walker and Morrison were in a volatile de facto relations…

alcohol
TAScommunity2018-06-12

Coroner's Finding: Osborn, James Lee

62y · Male·drowning

…ischarge from Royal Hobart Hospital on 24 June, he declined community mental health follow-up. He died by suicide approximately 4-5 days after discharge. Key clinical lessons: (1) High-risk patients discharged from acut…

psychiatryemergency medicinesystemcommunicationolanzapine
QLD2010-08-31

Muir, Jason Andrew

36y · Male·Effects of hanging

…ess and suicidal ideation, died by hanging in Arthur Gorrie Correctional Centre. He had been removed from suicide observation in June 2008 following improvement on antipsychotic medication (Quetiapine, Mirtazapine). He …

psychiatrycorrectional healthsystemdelayquetiapine
SAhome2025-11-27

Coroner's Finding: Gifford, Paul Douglas

36y · Male·acute neck compression due to hanging

…oids), mental health issues including borderline personality disorder, childhood sexual trauma, and prior suicide attempts. In May 2021, after drug use with his partner and relationship conflict, he made two suicide att…

psychiatryaddiction medicinemethamphetamine
VIC2012-09-21

Timothycaseypart1 127708

29y · Male·hanging

…sment and care. At Melbourne Assessment Prison, Nurse T D assigned Casey a P3 rating despite six previous suicide attempts, substance abuse, and schizophrenic symptoms. After self-harm on 29 February, registrar Dr S T u…

psychiatrycorrectional healthdiagnosticcommunicationheroin
VICmental health2012-04-03

Finding into death of Miles David Colman

21y · Male·Head injury sustained in fall from height

…psychiatric unit 10 days earlier with paranoid delusions and command hallucinations telling him to commit suicide. Over the first week, his condition improved significantly on Risperidone and Lorazepam; he was moved fro…

psychiatryintensive carerisperidone
TAShome2023-07-24

Coroner's Finding: QD de-identified

45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…

…e, quetiapine, and paracetamol with alcohol. The coroner classified the death as misadventure rather than suicide. Clinical lessons include: GPs prescribing high-risk opioids must conduct regular risk-benefit assessment…

general practicepsychiatrydelaysystemtapentadol
VICmental health2015-10-30

Finding into death of Jarrod Wade Christie

23y · Male·injuries sustained when struck by train

… Christie, 23, a voluntary then involuntary psychiatric inpatient at Maroondah Hospital, absconded from the high-dependency unit on 22 December 2012 and died by suicide. Clinical lessons include: (1) GPs should fully rev…

psychiatrygeneral practicecommunicationsystemdesvenlafaxine
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

…ng in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide exposure, presenting with major depression…

psychiatryemergency medicinesystemcommunicationmirtazapine
134521

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