Coronial

99 results for assessment order under mental health act

ACThome1998-03-06

Inquest Into The Circumstances Surrounding The Death Of Brian Joseph Duff

36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…

…city (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case management. Critical failures in the mental health system contributed to his death: the Cri…

psychiatrycommunicationsystemclozapine
WAhospital2012-08-31

Inquest into the Death of Stone

62y · Female·Multiple injuries sustained from jumping from rocks at Torndirrup National Park …

…ch 2009 after a violent altercation at home, having been sedated by paramedics. She was placed on a Form 1 mental health assessment order by Dr L.. However, the G Ward psychiatric unit had no bed capacity, and both avail…

emergency medicinegeneral practicesystemcommunicationmidazolam
SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on…

psychiatrycorrectional healthsystemcommunicationmethamphetamine
NSW2020-05-06

Inquest into the death of Jonathon HOGAN

23y · Male·Neck compression as a result of hanging

…nia with previous suicide attempts and was un-medicated for months before arrest. Critical failures in his mental health care included: delayed initial psychiatric assessment (3 weeks), inadequate intake screening that f…

psychiatrygeneral practicediagnosticcommunicationolanzapine
SAmental health2020-12-15

Coroner's Finding: BARTON Stephen John

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

…m 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 ideation, had been in ED for 3 days before a…

psychiatryemergency medicinediagnosticsystemrisperidone
SAmental health2017-11-29

Coroner's Finding: MICHIE Tiffany Jayne.docx

22y · Female·plastic bag asphyxia, possibly contributed to by neck compression

…an with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asphyxiation as a c…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
WAcommunity2024-06-26

Inquest into the Death of Peter James WILSON

41y · Male·complications in association with effects of fire, with terminal palliative care

Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by sui…

psychiatryintensive carecommunicationsystempaliperidone
NSWhospital2015-07-02

Inquest into the death of N

69y · Female·Asphyxiation consistent with hanging

…woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While individual investi…

neurologypsychiatrydiagnosticcommunicationphenytoin
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

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

…sion, and multiple suicide attempts, died by hanging in the Northern Psychiatry Unit on 24 June 2010 while under involuntary psychiatric admission. She had presented to emergency with acute suicidality on 18 June, atten…

psychiatryemergency medicinecommunicationsystemquetiapine
VICmental health2018-09-17

Finding into death of Paquita Goldberg

87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…

… paranoia, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February 2013, she experienced escalating distress, disclosed prior se…

psychiatrygeriatric medicinecommunicationsystemdesvenlafaxine
WAhospital2017-07-11

Inquest into the Death of Beasley (also known as Graeme Leslie Syme)

49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …

…hlights risks of paradoxical harm when notification requirements conflict with risk management; in modern practice, escalated mental health assessment and immediate crisis intervention protocols following notification o…

emergency medicinetrauma surgerysystemdelaymethamphetamine
VICcommunity2021-03-10

Finding into death of Jack David watson

26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases

…ack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to B…

psychiatryemergency medicinecommunicationsystemdextroamphetamine
NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer hist…

psychiatrygastroenterologydiagnosticsystempantoprazole
VIChospital2024-07-29

Finding into death of Shane Anthony Pappas

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

…medications on 29 June 2021. He had experienced a recent relationship breakdown and presented to Grampians Health (GH) with multiple suicide attempts within 72 hours. The Coroner found several key deficiencies in his men…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLDhome2025-10-10

Inquest into the death of AB

31y · Male·Hanging

31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple …

psychiatrygeneral practicesystemcommunicationalcohol
QLD2025-10-01

Inquest into the death of Duke Allan Wayne Schafer

36y · Male·Ligature strangulation

…entencing judge, he consistently refused engagement. Bloomfield could not be compelled to accept treatment under mental health legislation as he did not meet criteria for involuntary treatment—he had capacity to refuse …

psychiatrypsychologysystemcommunicationbuprenorphine
WA2024-02-06

Inquest into the Death of Phillip John ALLEN

47y · Male·ligature compression of the neck (hanging)

A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, w…

psychiatrycorrectional healthcommunicationsystem
NTcommunity2009-06-10

Inquest into the death of Robert Plasto-Lehner and David Gurralpa aka Moscow

Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…

…rt disease, died of restraint asphyxia following police restraint in hospital while awaiting psychiatric assessment. Both men became acutely agitated during restraint and ceased struggling suddenly, which should have tri…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
NSW2021-05-12

Inquest into the death of Jack KOKAUA

30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …

…om malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asphyxia, exertion, taser use (deployed three times), and his underlying heart disea…

emergency medicinepsychiatryproceduralcommunicationzuclopenthixol

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