Coronial

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WAprison2017-02-28

Inquest into the Death of Jayden Stafford BENNELL

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

…eaning storeroom on 6 March 2013. He had a complex psychiatric history including drug-induced psychosis, depression, and anxiety, for which he was frequently non-compliant with antipsychotic medications. Critical clinica…

psychiatrycorrectional healthcommunicationsystemquetiapine
TAScommunity2020-08-13

Coroner's Finding: Wright, Maria Rebekah

31y · Female·drowning, deliberately self-inflicted with intention of ending life

Maria Rebekah Wright, a 31-year-old woman with severe borderline personality disorder and chronic suicidality, died by drowning at Howrah Beach, Tasmania on 14 August 2017. She had been discharged from Royal Hobart Hospi…

psychiatrypsychologyparacetamol
WAmental health2005-08

Inquest into the Death of Ward

44y · Male·Ligature compression of the neck (hanging)

Geoffrey Stephen Ward, a 44-year-old involuntary psychiatric patient at Graylands Hospital with chronic paranoid schizophrenia, died by hanging on 20 February 2000. He had been progressing well on antipsychotic medicatio…

psychiatryforensic medicineolanzapine
SAhospital2022-06-17

Coroner's Finding: THREDGOLD, Holly Alexandra

42y · Female·hanging

Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…

emergency medicinepsychiatrycommunicationdiagnosticsertraline
VICcommunity2012-04-12

Finding into death of Rajesh Pala

34y · Male·Mixed drug toxicity

… Pala, a 34-year-old man with polysubstance abuse disorder, borderline personality disorder, and chronic depression, died from mixed drug toxicity following discharge from The Alfred psychiatric unit. He was admitted to …

psychiatryaddiction medicinecommunicationheroin
WAhospital2016-03-24

Inquest into the Death of Jesse Richard DELLAR

17y · Male·ligature compression of the neck (hanging)

Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentio…

psychiatrygeneral practicediagnosticsystematomoxetine
VICcommunity2019-02-25

Finding into death of DH

40y · Female·Clozapine toxicity in a woman with cardiomegaly

A 40-year-old woman with depression, anxiety, alcoholism and undiagnosed cardiomegaly died from clozapine toxicity after obtaining the drug …

psychiatrygeneral practicesystemcommunicationclozapine
NSWmental health2014-05-08

Inquest into the death of Hugh David LISLE

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 psychiatric facility after admission f…

psychiatryemergency medicinecommunicationsystemdiazepam
VIChome2024-03-13

Finding into death of S L

38y · Male·Mixed drug toxicity including metonitazene

A 38-year-old man with a long history of substance use, depression, anxiety and ADHD died from mixed drug toxicity involving metonitazene. He believed he was injecting her…

psychiatrygeneral practicemetonitazene
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

…y, and sleep apnoea created high arrhythmia risk, particularly concerning given drug-induced respiratory depression risk in OSA patients. The cause of elevated medication levels remained undetermined, highlighting the di…

psychiatrycardiologycommunicationsystemclozapine
WA2016-10-07

Inquest into the Death of Gerardus Gerritt HEIJNE

49y · Male·Ligature compression of the neck (hanging)

A 49-year-old sentenced prisoner died by suicide via ligature compression of the neck at Acacia Prison in Western Australia. The deceased had a psychological profile characterised by denial and minimisation of adverse ex…

psychiatrygeneral practicedelaycitalopram
TASprison2024-04-18

Coroner's Finding: Gerard, Robert Harold

48y · Male·Hanging (partially suspended hanging using shoelaces as ligature)

… serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depression and suicidal ideation. The coroner found his mental health care was reasonable but limited by grossly in…

psychiatrycorrectional healthsystemdelayzuclopenthixol decanoate
WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

Peta Dawson, a 26-year-old woman with a history of depression, self-harm, and suicidal ideation following miscarriage and maternal rejection, was admitted to Merredin…

emergency medicinepsychiatrysystemdelaykalma
NT2001-12-19

Inquest into the death of Johnno Wurramarba

15y · Male·compression of the neck by hanging

…al health assessment on admission despite reported petrol sniffing and cannabis withdrawal; (5) possible depression and psychotic symptoms (hearing voices) not adequately documented or investigated; (6) inadequate room p…

paediatricspsychiatrydiagnosticproceduralcannabis
WAhospital2018-09-10

Inquest into the Death of Theodore Herbert Eric JOHANSEN

50y · Male·Drowning

Theodore Johansen, a 50-year-old man with a history of anxiety and depression, presented to his GP on 28 October 2014 with active suicidal ideation and a detailed plan to drown himse…

psychiatryemergency medicinediagnosticcommunicationamitriptyline
VIChome2009-06-02

Finding into death of Mark Andrew Downie

32y · Male·overdose of a combination of chlorpromazine, mirtazapine, and diazepam

…m at home on 16 January 2007, eleven days after discharge from psychiatric hospital. He had a history of depression, polysubstance abuse, and recent suicide attempts while imprisoned. Despite hospital staff awareness of …

psychiatrysystemdelaychlorpromazine
NSWcommunity2020-09-04

Inquest into the death of Thomas HUNT

27y · Male·unascertained; likely death from entering water

Thomas Hunt, a 27-year-old man, died after entering the water near Bondi Beach on 23 March 2017, likely after experiencing an acute mental health crisis characterised by paranoid delusions and auditory hallucinations. Mu…

psychiatrygeneral practicediagnosticcommunication
VIChospital2011-08-16

Finding into death of Lisa Irene Sharp

34y · Female·Hanging with combined effects of ethanol and benzodiazepines

Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of …

psychiatryemergency medicinediagnosticcommunicationdiazepam
QLDhospital2016-09-15

Mr B, a 41 year old indigenous man - Non-inquest findings

41y · Male·Subdural haematoma

…; failure to obtain CT imaging despite red flags; continued diazepam administration despite signs of CNS depression (drowsiness, incontinence, fixed pupils); and delayed notification of medical staff about clinical deter…

emergency medicineneurologydiagnosticcommunicationdiazepam
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

…wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression dating from age 14, treated with antipsychotic medication with variable compliance. In the weeks before …

psychiatryemergency medicinedelaymethamphetamine
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