Coronial

167 results for acute mental health deterioration

NSWhome2020-06-01

Inquest into the death of A P

2y · Female·drowning

A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurre…

general practicepsychiatrycommunicationsystemtriflouperazine
VICmental health2013-02-25

Finding into death of Joy Apostolopoulos

41y · Female·Multiple injuries due to impact by train

…after absconding from a locked psychiatric ward at Alfred Hospital. She had been on escorted leave, became acutely agitated upon returning home, and was brought back to the ward by ambulance at 7:31pm. Critical failures…

psychiatryemergency medicinecommunicationsystemclozapine
VICmental health2015-02-02

Finding into death of CB

27y · Female·hanging

…isorder died by hanging while voluntarily admitted to a psychiatric inpatient unit. She had presented with acute suicidality following relationship breakdown and job loss, with two recent suicide attempts including hang…

psychiatryemergency medicinediagnosticcommunicationquetiapine
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

…r-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite being involuntary patients on observation regimes with leave …

psychiatrydiagnosticcommunicationhaloperidol
VIC2024-07-01

Finding into death of Joshua Steven Kerr

32y · Male·methylamphetamine toxicity

…ital, he was removed by correctional officers without formal medical discharge. Upon return to prison, his acute behavioural disturbance from drug toxicity was not recognised as requiring hospital transfer. A rigid 'TOG…

emergency medicinepsychiatrydiagnosticcommunicationmethamphetamine
NSWhome2022-09-13

Inquest into the death of Ian Fackender

47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…

…t Order breach enforcement operation in his home. He had severe, treatment-resistant schizophrenia and was acutely psychotic during the incident. Critical failures occurred throughout: inadequate risk assessment and pla…

psychiatryforensic medicinecommunicationsystemaripiprazole
VICcommunity2015-05-29

Finding into death of Craig Doherty

49y · Male·Multiple injuries from a fall from height

…se and alcohol intoxication, presenting with manic relapse. On the day of death, he was seen by his GP and mental health crisis team, both noting deterioration, paranoid delusions, and non-compliance with Olanzapine. Des…

psychiatrygeneral practicelithium
QLDhospital2015-03-13

Cuttler, Melina Maree

29y · Female·Multiple injuries due to fall from height

A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. …

emergency medicinepsychiatrydiagnosticcommunication
TAShospital2020

Coroner's Finding: Bond, Johnathon Lee

51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)

A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …

psychiatryemergency medicinesystemdelayamisulpride
VICmental health2014-12-23

Finding into death of David John McLeod

58y · Male·Cardiomegaly and severe single vessel coronary artery atherosclerosis in a man w…

…an with schizoaffective disorder, was admitted to a psychiatric inpatient unit on 21 August 2012 following mental health deterioration. He presented with signs of infection, received appropriate clinical assessment and i…

psychiatrygeneral medicinerisperidone
VIChospital2018-02-28

Finding into death of Samuel Carl Johansen

36y · Male·Multi-organ failure complicating injecting drug use

… substance abuse was admitted involuntarily to a psychiatric unit on 15 September 2012 after community deterioration. He improved over several weeks and was transitioned to voluntary status on 15 October. On 23 October,…

psychiatryintensive carecommunicationdelayheroin
SAhospital2020-06-17

Coroner's Finding: TIERNAN John Joseph

78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect

…lia intracerebral haemorrhage with mass effect while admitted under an Inpatient Treatment Order (ITO) for acute hyperactive delirium. He had stage 4 lung cancer with extensive brain metastases discovered on MRI. His de…

psychiatryneurology
WAhospital2005-03

Inquest into the Death of Bert Sharpe

58y · Male·Gastrointestinal haemorrhage due to erosive gastritis

…ury sustained in a motor vehicle accident in 1970. This injury caused chronic brain damage and progressive mental health deterioration requiring lifelong institutional care. In April 2004, he was admitted to hospital wit…

psychiatrygeneral surgery
TAScommunity2025-06-30

Coroner's Finding: de-identified XA

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

…phrenia died by suicide, jumping from the Tasman Bridge on Christmas Eve 2022. He had a 15-year history of mental illness with multiple suicide attempts, previously managed with antipsychotic injections and antidepressan…

psychiatrygeneral practicesystemdelaypaliperidone
VIChome2025-08-28

Finding into death of MJU & KJH

39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back

…m reporting CTH's hallucinations, paranoia and drug use, paramedics and police assessed him as not meeting Mental Health Act thresholds for involuntary admission. The coroner identified system failures in Child Protectio…

psychiatryemergency medicinediagnosticcommunicationmethamphetamine
TAScommunity2021-01-25

Coroner's Finding: Townsend, David Lester

69y · Male·Partial contact range gunshot wound of the head

…eptember 2017. He had been receiving psychiatric care from Dr McDougall and case management from community mental health services. Following a July 2017 hospitalisation for acute depression and suicidality related to an …

psychiatrygeneral practice
QLDhospital2012-09-28

Harold, Rex

59y · Male·disseminated carcinoma due to right lung carcinoma

…ted to pneumonia; malignancy was suspected but could not be confirmed before death due to his clinical deterioration. The autopsy revealed aggressive disseminated lung cancer with extensive spread. Expert review by Prof…

general medicinecardiologydiagnostic
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

… with recently diagnosed Stage 4B non-Hodgkin lymphoma and pre-existing depression managed by Orygen Youth Health, died by suicide on 22 September 2016 by jumping from the seventh-floor rooftop garden of Peter MacCallum …

psychiatryhaematologycommunicationdelaymetoclopramide
QLD2012-08-07

Bucknall, David John

41y · Male·Hanging

…l and received psychiatric care after referral, though there was a two-month delay in accessing the Prison Mental Health Service due to resource limitations. His psychiatrist provided good care and found no evidence of a…

psychiatrygeneral practicesystemdelaymirtazapine
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

…der and recurrent depression experienced a relapse while in Tasmania and was referred to a community-based Acute Care Team in Queensland in November 2009. Despite his partner repeatedly requesting hospitalisation and ex…

psychiatrygeneral practicediagnosticcommunicationsertraline
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