Coronial

1,120 results for suicidal ideation

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TAShome2021-12-03

Coroner's Finding: Summers, Damian

42y · Male·hanging, an action taken by himself with the intention of ending his life

…rural island where his partner and children had left. He had poor insight into his mental illness, denied suicidal ideation throughout admission, and had low suicide risk scores. He died by suicide within 24 hours of dis…

psychiatrygeneral practicecommunicationsystemolanzapine
SA2017-06-28

Coroner's Finding: MCCONNAL Brenton Winton

47y · Male·gunshot wound of the head (self-inflicted)

A 47-year-old man with delusional disorder was discharged from mental health detention with a firearm prohibition order. He attended a commercial firing range and fatally shot himself. The coroner found his death was pre…

psychiatryforensic medicinesystemcommunicationpaliperidone
SAmental health2004-04-20

Coroner's Finding: TAYLOR Michael Jason

27y · Male·Not determined; olanzapine toxicity suspected but regarded by expert evidence as…

Michael Jason Taylor, aged 27, died on 26 February 2000 while detained at Glenside Hospital under the Mental Health Act 1993. He was a patient with chronic schizophrenia, borderline intelligence, and a history of drug-se…

psychiatrytoxicologysystemcommunicationolanzapine
NSWhome2022-05-27

Inquest into the death of WX

54y · Male·gunshot wound to the head

WX, a 54-year-old with longstanding depression, substance abuse (opioids, benzodiazepines), and a 2008 suicide attempt, died by gunshot wound on 27 April 2015. Despite this psychiatric and substance abuse history, he hel…

psychiatrypsychologysystemcommunicationcodeine
SA2007-09-19

Coroner's Finding: SMITH Arthur Charles

30y · Male·hanging

Arthur Smith, a 30-year-old man remanded in custody, died by hanging in Yatala Labour Prison on 13 January 2005. He had a complex psychiatric history including borderline personality disorder, chronic depression, polysub…

psychiatrycorrectional healthsystemcommunicationmirtazapine
WAhome2017-03-30

Inquest into the Death of Troy William MURRAY

34y · Male·ligature compression of the neck (hanging)

Troy William Murray, a 34-year-old man with a long history of substance abuse (primarily amphetamine and alcohol), psychiatric illness, and multiple previous suicide attempts, died by hanging on 11 March 2012. He had bee…

psychiatrygeneral practicecommunicationamphetamine
SA2018-01-17

Coroner's Finding: COSTI John Steve

39y · Male·neck compression (due to hanging) and plastic bag asphyxia

John Steve Costi, aged 39, died by suicide in Adelaide Remand Centre on 27 November 2013. He fashioned a ligature from bedding strips and hanged himself using an unusual hanging point in his single cell between 4am and 6…

correctional healthpsychologysystemdelay
VIC2015-10-05

Finding into death of Catherine Jane Bernard

17y · Female·multiple injuries due to impact by train

A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clin…

emergency medicinepsychiatrycommunicationsystemtemazepam
NThome2003-12-19

Inquest into the death of Sunjay Chandra

25y · Male·hanging (self-inflicted)

A 25-year-old man with schizophrenia died by suicide while on a Community Management Order following discharge from psychiatric hospital. He had been effectively stabilized on clozapine for years, but in late 2001 reques…

psychiatrypsychologycommunicationsystemclozapine
VIChome2025-09-11

Finding into death of ZSQ

26y · Female·Multiple stab wounds

ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…

emergency medicinepsychiatrycommunicationsystemcocaine
VICcommunity

Tylercassidypart2 554208

Male·Multiple gunshot wounds from police shooting

Tyler Cassidy, 18, died after police shot him multiple times when he advanced on them with two knives in a public park. The coroner found that while Tyler's actions were deliberate, they were not voluntary—he was overwhe…

psychiatrycommunicationsystemalcohol
VICmental health2014-12-05

Finding into death of Wieslaw Albin Bernacki

62y · Male·hanging

A 62-year-old man with a long history of severe schizophrenia died by hanging after being granted escorted day leave from a psychiatric inpatient unit. The coroner identified critical failures in communication between ho…

psychiatrycommunicationsystemantipsychotics
VIC2026-03-30

Finding into death of Hari Prasad Dhakal

57y · Male·Neck compression and hanging

…ith persistent lack of insight. He refused psychiatric appointments in June-July 2024 but showed no overt suicidal ideation or self-harm. The coroner found no evidence the death was foreseeable and noted his psychosis wa…

psychiatrygeneral practicesystemcommunicationpaliperidone
NThome2009-09-28

Inquest into the death of Danny Borrak Gumana

19y · Male·Intentional self-inflicted hanging

A 19-year-old Aboriginal man from East Arnhem 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 wa…

psychiatrytoxicologyalcohol
VIChome2021-10-12

Finding into death of Mr A

51y · Male·Hanging

A 51-year-old man with mild intellectual disability from childhood head injury died by hanging following family violence separation. He perpetrated physical, emotional and verbal abuse against his wife and children over …

general practicepsychiatrycommunicationdiagnosticvenlafaxine
QLDcommunity2024-08-21

Inquest into the deaths of Charmaine, Aaleyn, Matilda, Wyatt, and Zaidok McLeod

Female·multiple injuries from motor vehicle collision (for all five deceased)

Charmaine McLeod died by intentionally driving her vehicle into an oncoming truck, killing herself and her four young children (aged 2-6). She had a longstanding history of complex mental health issues (Borderline Person…

psychiatryemergency medicinesystemcommunicationfluvoxamine
NSW2025-03-06

Inquest into the death of Leah Jane Porter

50y · Female·hanging

A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …

psychiatrygeneral practicecommunicationsystemmethylphenidate
QLD2024-04-30

WILLIAMS, Russell James

51y · Male·Incised wound to the right arm

Russell Williams, aged 51, died by suicide in a Queensland prison on 15 May 2018 by cutting his right arm with a disposable razor blade. He was remanded on two historical murder charges and had spent 15 years in prison o…

psychiatrypsychologydiagnosticsystem
NSW2019-06-19

Inquest into the death of M A

44y · Male·Hanging

A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…

psychiatrygeneral practicediagnosticcommunicationescitalopram
SAhome2011-04-07

Coroner's Finding: LEE Troy Thomas and MATTHEWS Scott Leslie

Troy Thomas Lee: acute neck compression due to hanging; Scott Leslie Matthews: m…

Two men died by suicide while on home detention bail awaiting trial. Troy Thomas Lee (38, hanging) and Scott Leslie Matthews (23, mixed drug toxicity from tramadol and alprazolam overdose) both died on their parents' pre…

general practicepsychiatrycommunicationdelaytramadol
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