Coronial

390 results for mental health deterioration

NSWprison2021-11-19

Inquest into the death of Danny Whitton

25y · Male·Multiple organ failure due to acute paracetamol poisoning

…endance delayed hospitalisation. By 7 November Danny had a Glasgow Coma Scale of 11 indicating serious deterioration, yet was not transferred to hospital until afternoon despite clear clinical indicators warranting imme…

emergency medicinetoxicologydiagnosticcommunicationparacetamol
VIChome2025-01-31

Finding into death of FCP

45y · Female·Drowning whilst inebriated (ethanol)

…ning while inebriated on 11 April 2020 at her home in Kilmore East, Victoria. She had a complex history of mental illness (psychosis, depression, anxiety, PTSD), substance abuse, and was in a relationship with controllin…

psychiatryemergency medicinesystemcommunicationalcohol
VIChospital2016-10-04

Finding into death of Damien Marius Van Der Korput

50y · Male·Hypoxic ischaemic brain injury in the context of hanging

A 50-year-old man with longstanding depression, anxiety, and ADHD died by hanging after an acute deterioration in mental state. He had previous psychiatric admission in 2012 for suicidality and was under regular p…

psychiatryemergency medicinecommunicationsystemalcohol
NT2023-02-24

Inquest into the death of Bernard Hector

31y · Male·self-inflicted hanging

… 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearance. A mental health assessment on 14 July 2021 found no mental illness or acute suicide risk, leading to removal from '…

psychiatrycorrectional healthcommunicationsystem
VIChospital2014-10-01

Finding into death of Raymond John O_Brien

71y · Male·acute myocardial infarction due to coronary artery disease

… Following a schizophrenic relapse, he became non-compliant with cardiac medications. Despite clinical deterioration and a second ambulance call, a joint medical-psychiatric team decided against coercive transfer, judgi…

cardiologypsychiatryaspirin
VIChome2024-03-07

Finding into death of Claire Louise Carroll

45y · Female·Neck compression secondary to hanging

… symptoms including auditory hallucinations, paranoid delusions, and persecutory ideation. She had complex mental health diagnoses (borderline personality disorder, schizoaffective disorder, complex PTSD) and a history o…

psychiatrygeneral practicesystemcommunicationclonazepam
VICcommunity2014-08-13

Finding into death of Frederick Russell Morgan

48y · Male·Unknown causes (presumed suicide by drowning)

Frederick Russell Morgan, a 48-year-old stockbroker, disappeared on 15 July 1971 from Mt Martha beach. He had experienced severe depression triggered by business financial crises, tax assessment concerns, and his father'…

psychiatrypsychologydiagnosticdelayantidepressant medication
WAmental health2016-03-02

Inquest into the Death of Mark Warton BENNETT-ROBERTSON

25y · Male·ligature compression of the neck (hanging)

…er noted that current policy now requires immediate police notification for absconding patients at risk of mental state deterioration due to medication non-compliance.

psychiatryemergency medicinecommunicationdexamphetamine sulphate
SA2021-11-04

Coroner's Finding: Papageorgiou, Theo Nickolas

27y · Male·compression of the neck due to hanging

…r-old man with a history of psychotic and manic symptoms since November 2014, was briefly detained under a mental health order in November 2015 but discharged after only six days despite continued florid psychotic sympto…

psychiatrygeneral practicediagnosticcommunicationolanzapine
NTcommunity2018-12-03

Inquest into the death of Sabrina Di Lembo

19y · Female·self-inflicted hanging

…stic tools. Dr B. prescribed sub-therapeutic Efexor 37.5mg (minimum recommended dose 75mg), leading to deterioration attributed to the medication. When Sabrina stopped the drug, neither GP escalated to psychiatry or the…

general practicepsychiatrydiagnosticmedicationvenlafaxine
SAcommunity2004-09-10

Coroner's Finding: CORNISH Peter Henry

43y · Male·aspiration of vegetable matter with occlusion of the upper airway

…ncing a severe manic episode. In the two weeks before his death, multiple warning signs of psychiatric deterioration were documented: erratic behaviour, sleep deprivation, religious preoccupation, and fire-setting. Desp…

psychiatryemergency medicinediagnosticsystemcannabis
SAhospital2012-11-14

Coroner's Finding: Johnson Peter Andrew

61y · Male·paraneoplastic syndrome caused by metastatic adenocarcinoma of the lung

…07. Subsequent brain metastases developed in September 2007 requiring multiple surgical interventions. His mental state deteriorated due to advanced cancer, resulting in a 21-day Mental Health Act detention order. He was…

oncologyneurosurgery
SAhospital2020-05-08

Coroner's Finding: HALL Bryan Robert

71y · Male·general inanition on a background of end-stage mixed pattern dementia and acute …

…'s and vascular dementia, seizures, and chronic renal disease. His final admission followed behavioral deterioration and urinary tract infection. During hospitalization, he experienced multiple falls related to dementia…

geriatric medicinepsychiatry
VIC2026-03-05

Finding into death of Darryn Leslie Beaton

22y · Male·Unascertained

…survival. The coroner concluded he is deceased but the exact cause remains unascertained, likely involving mental health decompensation, becoming lost in bushland, and death from exposure or possible suicide. This case h…

psychiatry
WAcommunity2025-09-15

Inquest into the Suspected Death of Nicholas Lutci PAVLIDIS

Male·unascertained

…d inability to contact the owner, may have identified his disappearance sooner. Mr Pavlidis had documented mental health deterioration including paranoia, anxiety, and isolation; he had ceased taking prescribed medicatio…

general practicepsychologysystemdelayfluoxetine
QLD2025-10-29

Inquest into the death of Selesa Tafaifa

44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…

…elative contributions could not be established. Clinical lessons include: recognising signs of medical deterioration during restraint in vulnerable prisoners with comorbidities; removing safety hoods when distress is ev…

forensic medicineemergency medicineproceduralsystemmixtard 30/70 insulin
VICcommunity2017-10-24

Finding into death of Glenn Albert Sanders

48y · Male·Injuries sustained in an explosion

…nders died from injuries sustained in explosions on his property during a police siege. Sanders had severe mental illness (Delusional Disorder/Schizophrenia), polysubstance abuse, and had rigged his house and farm buildi…

psychiatrygeneral practicecommunicationsystemrisperidone
VICmental health2020-12-18

Finding into death of Michelle Williams

46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia

…ses were assisting in the HDU; failure to perform a required formal risk assessment despite observable deterioration in her mental state that morning; and inadequate environmental controls allowing plastic bags in the i…

psychiatryintensive caresystemdiagnosticolanzapine
NSWcommunity2018-10-24

Inquest into the death of Michael Joyce

28y · Male·Multiple injuries sustained from fall from cliff

… Joyce, 28, died after stumbling and falling from a cliff at Dunningham Reserve, Coogee while experiencing mental disturbance. He had a history of insomnia-related mental health issues (previous psychosis, hospitalisatio…

emergency medicinepsychiatrytemazepam
TAScommunity2021-09-02

Coroner's Finding: Sterling, Barbara Lynette

69y · Female·Drowning

…ause of death with no toxicological abnormalities. Prior to her death, there was evidence of deteriorating mental health including reported paranoid behaviour, anxiety, and depression documented in her GP records. Howeve…

forensic medicinegeneral practice
145620

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