Coronial

402 results for suicide risk high

NSWcommunity2023-05-25

Inquest into the disappearance and suspected death of Melissa CADDICK

49y · Female·Cannot be determined

…ly dismissed homicide possibilities prematurely, failing to refer the case to the Homicide Squad despite a 'High Risk' assessment and concerns about her husband's credibility. CCTV canvassing was delayed, risking evidenc…

psychiatryforensic medicinedelaysystem
QLDcommunity2019-08-02

Ms D - Non-inquest findings

47y · Female·Overdose of hydromorphone

…bed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following separation from her violent partner. Multiple health and social car…

psychiatrygeneral practicediagnosticcommunicationhydromorphone
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

…d chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding assessment, psychiatrist Dr L. concluded the patient had decision-maki…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
NSWprison2021-06-11

Inquest into the death of F

49y · Male·hanging

…in his prison cell while serving a 16-year sentence for murdering his three children. Despite a chronically high suicide risk and prior suicide attempts, he received inadequate psychiatric and nursing review in his final…

psychiatrycorrectional healthcommunicationsystemolanzapine
VICcommunity2020-02-28

Finding into death of Robb Thomas Lawson

48y · Male·unascertained

…8-year-old man with a long history of mental illness including depression, anxiety, paranoia and multiple suicide attempts, disappeared in July 2007 after declining psychiatric care. He had been managed by Dr F. and was…

psychiatrycommunicationolanzapine
VIChome2020-04-23

Finding into death of Baillee Petra Schneider

25y · Female·Compression of the neck

Baillee Schneider, a 25-year-old woman, died by suicide via neck compression while intoxicated. She had a history of substance misuse (cocaine, alcohol), anxiety…

psychiatrytoxicologyalcohol
TASaged care2020-06-19

Coroner's Finding: Konstantinidis, Agis

90y · Male·aspiration pneumonia due to pulmonary fibrosis and dementia

…ry fibrosis died of aspiration pneumonia at a residential aged care facility. He had experienced multiple suicide attempts including wrist cutting and methylated spirits ingestion, leading to an emergency guardianship o…

geriatric medicinepalliative careantidepressant medication
NSWmental health2017-02-28

Inquest into the death of RC

53y · Male·Gunshot wound to the head

RC, a 53-year-old man with longstanding depression, died by suicide on 15 April 2014. He was under care of Campbelltown Community Mental Health (CoMHET) when a critical clin…

psychiatrypsychologycommunicationsystemlithium
VIChome2022-02-23

Finding into death of Mark Edward Elliott

58y · Male·Shotgun wound to the neck

Mark Edward Elliott, a 58-year-old prominent lawyer, died by suicide on 13 February 2020 following a shotgun wound to the neck. He was experiencing significant occupational a…

general practiceemergency medicinediagnosticcommunicationzolpidem
TAShome2024-08-05

Coroner's Finding: de-identified TJ

82y · Male·Self-inflicted partial contact shotgun wound of the head

…n January, he told his GP the treatment made him feel 'terrible' and he'd 'rather be dead,' but no formal suicide risk assessment or mental health referral was documented. No communication occurred between treating onco…

oncologygeneral practicecommunicationsystem
WAhome2019-09-27

Inquest into the Death of Paul STRANGE

30y · Male·ligature compression of the neck (hanging)

Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for …

psychiatryemergency medicinecommunicationsystemduloxetine
NSWhome2016-07-05

Inquest into the death of Jason BRITTEN

30y · Male·Cause of death remains uncertain; likely drug-related but not established

… Britten, a 30-year-old man with a long history of heroin use and mental health issues including previous suicide attempts, was found dead at his home in February 2015 after approximately three months of decomposition. …

psychiatryaddiction medicinedelayheroin
NThospital2011-07-29

Inquest into the death of Nicholas Edward Spring

25y · Male·hanging

…paranoia and suicidal ideation four months later. He was readmitted to hospital as a voluntary patient with high suicide risk and permitted family leave. The coroner found no error in the clinical decision to cease medic…

psychiatryemergency medicinecommunicationsystemzuclopenthixol decanoate
SAhospital2000-06-16

Coroner's Finding: WANGANEEN Fallon

26y · Male·neck compression due to hanging

…-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key clini…

psychiatryemergency medicinediagnosticcommunicationparacetamol/codeine
TAScommunity2023-07-24

Coroner's Finding: de-identified FR

27y · Female·carbon monoxide intoxication due to voluntary and intentional inhalation of exha…

A 27-year-old woman with a lengthy history of depression, anxiety, and previous suicide attempts died by carbon monoxide poisoning. She was referred to mental health crisis services on 4 July 2…

psychiatrygeneral practicecommunicationsystem
WA2020-11-28

Inquest into the Death of Wayne Thomas LARDER

42y · Male·ligature compression of the neck (hanging)

…on, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management included: (1) mental health staff lacked access to Statement of Material Facts and PSOLIS…

psychiatrypsychologydiagnosticsystemmethamphetamine
SAmental health2023-03-03

Coroner's Finding: Paxford, Mathew George

27y · Male·hanging

…athroom door. The coroner found he should not have been left unattended given the accumulated evidence of suicide risk, though strict 15-minute observation alone may not have prevented death. The bathroom door had not b…

psychiatryemergency medicinecommunicationsystemdiazepam
NThome2009-09-28

Inquest into the death of Danny Borrak Gumana

19y · Male·Intentional self-inflicted hanging

… was transported home by police following a disturbance outside a nightclub. He had previously threatened suicide twice in recent weeks while intoxicated, and his behaviour was increasingly concerning (not attending wor…

psychiatrytoxicologyalcohol
QLDmental health2005-11-09

Community Mental Health Patient

20y · Male·hanging

… registrar and consultant before revoking an indefinite order; insufficient senior clinician involvement in high-risk access team assessments; failure to readmit despite documented suicidality and dangerous behaviour; an…

psychiatrygeneral practicediagnosticcommunicationsertraline
WAcommunity2021-03-25

Inquest into the Suspected Death of Jason Marcus LAWSON

32y · Male·unascertained; most likely exposure after walking in bushland

…old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on 11 December 2003, one week after discharge from an acute psychiatric admission f…

psychiatrypsychologycommunicationdelaycitalopram
145621

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