Coronial

129 results for acute psychiatric crisis

WAcommunity2005-11-04

Inquest into the Death of Sheridan Troy Hilton

42y · Female·Ligature compression of the neck (hanging)

…rioration, she was admitted to Busselton District Hospital on 18 August 2003 and transferred to Bentley Psychiatric Hospital on 21 August. Although assessed as a voluntary patient with protective factors (family support…

general practicepsychiatrycommunicationsystemmirtazapine
SAmental health2020-12-15

Coroner's Finding: BARTON Stephen John

43y · Male·blunt neck trauma from compression of the neck

Stephen John Barton, aged 43, died from blunt neck trauma inflicted by roommate Lindon Sekrst in a psychiatric ward. Both were detained patients under Mental Health Act orders. Sekrst, a 23-year-old with paranoid i…

psychiatryemergency medicinediagnosticsystemrisperidone
QLD2007-03-01

McGeary, Corey Allan

20y · Male·Self-inflicted hanging

…pitated by the stressful transfer. Key clinical lessons: (1) Vulnerable prisoners with chronic, complex psychiatric comorbidity should be flagged and require mental health consultation before destabilising events; (2) S…

psychiatrypsychologycommunicationsystemolanzapine
QLDPodcast2020-06-30

Ayliffe-Chung, Mia Mishka Annie and; Jackson, Thomas Leslie - Non-inquest findings

Unknown·Mia: Stab wound to heart; Thomas: Stab wound to brain

…ior criminal history and background checks were appropriate, systemic failures in recognizing and managing acute mental health crises in non-traditional settings were evident.

psychiatryemergency medicinesystemcommunicationcannabis
VIChome2023-11-20

Finding into death of Caitlin Mary O'Brien

31y · Female·Compression of the neck

…19, despite documented delusions and aggressive behaviour, Mr Sturt was discharged the same night after psychiatric assessment that appeared to minimise family violence risks and reflect his victim-blaming narrative. Vi…

psychiatryemergency medicinediagnosticcommunicationcannabis
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

… with hammer) and was assessed by CATT. Critically, the registered nurse did not conduct a face-to-face psychiatric assessment—the consultant psychiatrist made discharge decisions based only on phone discussion without …

psychiatryemergency medicinediagnosticcommunicationquetiapine
NSWcommunity2022-02-18

Inquest into the death of SP

36y · Male·hanging

A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…

emergency medicineparamedicinecommunicationsystem
SA2020-11-26

Coroner's Finding: KEN Kenneth Ngalatji

68y · Male·compression of the neck with contributing acute myocardial infarction due to cor…

…old Aboriginal man died by hanging in his cell at Yatala Labour Prison on 16 April 2015 while experiencing acute myocardial infarction. He was transferred to Yatala for urgent psychiatric assessment following two self-h…

psychiatrycardiologydiagnosticcommunicationolanzapine
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

…included: inexperienced control room staff failing to recognise his escape alarm, lack of continuity of psychiatric care across facility transfers, absence of face-to-face psychiatric assessment at Christmas Island, and…

psychiatrygeneral practicesystemcommunicationmirtazapine
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

41y · Male·head and chest injuries from fall from height

…each attempts. The patient had capacity to refuse treatment and couldn't be involuntarily detained without acute crisis. Earlier recognition of disengagement, proactive contact attempts, and family involvement (with con…

psychiatrygeneral practicesystemdelaypaliperidone
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…hol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania and psychosis, requiring compulsory psychiatric hospitaliz…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

…ossible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St Vincent's Hospital Mental Health Service (SVHM) in the week before …

psychiatryemergency medicinecommunicationsystemsertraline
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

…conded from his supported residential service and was found deceased. The coroner found Austin Health's psychiatric assessment and management suboptimal, highlighting failures to: utilise relapse prevention plans, antic…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
WAhospital2025-06-30

Inquest into the death of Houston PEEL

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

Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation …

emergency medicinepsychiatrycommunicationdelayolanzapine
SAcommunity2010-08-12

Coroner's Finding: BAIS Ricky James

38y · Male·ischaemic heart disease

…l asphyxia or other factors. Key clinical lesson: undiagnosed cardiac disease presenting atypically during acute psychiatric crisis requires consideration; coordination between mental health, police, and ambulance servi…

psychiatrygeneral practicesystemcommunicationdepot zuclopenthixol
QLDcommunity2009-06-19

Hatch, Clay

34y · Male·gunshot wound to the neck

Clay Hatch, aged 34, with longstanding schizophrenia and recent amphetamine use, became acutely psychotic and took a supermarket cashier hostage at knifepoint after attempting to locate a gun shop. Du…

psychiatryemergency medicinecommunicationsystemamphetamine
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

…s include: (1) Mental health clinicians must ensure immediate assessments occur when patients present with acute psychotic symptoms and elevated harm risk, not deferring for convenience or family preferences about polic…

psychiatryemergency medicinedelaycommunicationclozapine
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

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

David Geoffrey Godley, aged 30, died from exsanguination due to self-inflicted multiple stab and incised wounds to his neck, chest, and head on 24 April 2016 in Tasmania. He had a long history of psychosis and depression…

psychiatryemergency medicinedelaymethamphetamine
QLD2010-10-08

Barker, Jeremy Dylan

27y · Male·Hanging

…ng using a bed sheet attached to exposed window bars in the toilet. Critical failures included: housing an acutely suicidal patient in an area with accessible hanging points despite prior staff warnings about this risk;…

psychiatrycorrectional healthcommunicationsystemcarbamazepine
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

54y · Male·quetiapine toxicity in a man with ischaemic heart disease

…scharge request. The ED registrar's reassessment seven hours later was wholly inadequate without proper psychiatric evaluation. The ART clinicians did not adequately consider voluntary psychiatric admission. While St Vi…

psychiatryemergency medicinediagnosticcommunicationquetiapine

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