Coronial

129 results for acute psychiatric crisis

VIChome2021-12-06

Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

…lly, the case highlights: (1) the need for collateral physical health risk identification in mental health crisis responses; (2) the importance of assuming underlying cardiovascular disease in those with mental illness; …

psychiatryemergency medicinesystemcommunication
VICcommunity2017-08-25

Finding into death of Thomas Edward Mackenzie Hall

41y · Male·Injuries sustained in a motor vehicle incident (driver) in a man with coronary a…

…is mother's car unlicensed and at excessive speed into oncoming traffic. He had a documented history of psychiatric illness with multiple involuntary admissions, medication non-compliance, and recent suicidal ideation e…

psychiatryemergency medicinecommunicationsystemrisperidone
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

…e at imminent risk. However, later that night following a domestic incident, her mental state deteriorated acutely. Contributing factors included: fragmented care across multiple services (Brisbane and Sunshine Coast) w…

psychiatrygeneral practicecommunicationsystemstillnox
QLDcommunity2025-05-02

Non-inquest findings into the death of Mr T.

49y · Male·undetermined

…ne became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police attempted to locate him for involuntary admission. Despite …

psychiatrysystemcommunicationclozapine
VICmental health2011-07-22

Finding into death of Lionel Raymond Perry

44y · Male·Cardiomegaly

… died from cardiomegaly (enlarged heart due to concentric ventricular hypertrophy) while an involuntary psychiatric inpatient. He presented with hypertension and withdrawal symptoms on admission; initial management incl…

psychiatryemergency medicinecommunicationdocumentationmethadone
WA2004-12-14

Inquest into the Death of Damien George Garlett

18y · Male·Ligature compression of the neck (hanging)

…The coroner expressed concerns about the inability to transition chronic suicidal ideation monitoring into acute crisis response, lack of psychiatric assessment despite his psychotic history, and poor continuity of care…

psychiatrypsychologydiagnosticcommunication
SAhome2017-07-25

Coroner's Finding: MCKENZIE Deborah Francis

22y · Female·compression of the neck consistent with hanging

…al mental health assessment. Medical staff failed to obtain collateral information, wake her for proper psychiatric evaluation, or detain her under mental health legislation. That afternoon, three accused individuals sh…

general practiceemergency medicinediagnosticproceduralparacetamol
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

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

…der, polysubstance dependence, and 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. conclu…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate
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…

…ase and heart 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 sho…

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
NSWhome2021-07-07

Inquest into the death of Kimberley APPLEBY

56y · Female·acute pentobarbitone toxicity

56-year-old woman died from acute pentobarbitone toxicity in her Sydney apartment on 27-28 May 2016. She had a long history of mental health…

psychiatrypsychologysystemproceduralpentobarbitone
WAhospital2025-12-23

Inquest into the Death of Karl Albert STEINHAUSER

30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…

…al Health Act care. After two weeks of increasingly challenging management at Kalgoorlie Health Campus for acute psychotic exacerbation, he was transferred by RFDS to Fiona Stanley Hospital ICU, intubated due to severe …

psychiatryintensive caresystemdelayaripiprazole depot
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

…sment at that time. The case highlights challenges in predicting suicide risk, the importance of timely psychiatric review in custody, and the limitations of risk assessment in newly incarcerated first-time offenders un…

psychiatrycorrectional healthcommunicationsystemmirtazapine
WAhospital2024-04-08

Inquest into the Death of Child SK (Name Subject to Suppression Order)

13y · Female·complications of a head injury sustained when she deliberately stepped in front …

…admissions and the patient's initial treatment reluctance; Perth Children's Hospital appropriately managed acute presentations but faced a significant service gap—there was no step-up/step-down facility available betwee…

psychiatryemergency medicinesystemdelaysertraline
WAhospital2003-07

Inquest into the Death of Mark Andrew Burnside

45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…

Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…

general practicepsychiatrythioridazine
SAhospital2000-11-20

Coroner's Finding: MIDDLETON Geraldine Ruth

45y · Female·haemorrhage due to traumatic rupture of the liver

A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
VIChome2015-11-27

Finding into death of Sherry Ann Robinson

38y · Female·multiple stab injuries to the chest and abdomen

A 38-year-old woman was fatally stabbed by her former partner, Bradley Carolus, in May 2010. Three days before the homicide, Carolus had been apprehended by police under mental health legislation following a volatile epi…

psychiatryemergency medicinecommunicationsystemquetiapine
NThome2013-10-15

Inquest into the death of Gwyyneth Cassiopeia-Roennfeldt

36y · Female·Internal injuries consequent on being stabbed repeatedly by Rocky Manu, a man wi…

…ad been non-compliant with antipsychotic medication for 3.5 months before the fatal attack while remaining acutely psychotic and experiencing persecutory delusions. Critical failures included: no formal case manager ass…

psychiatrysystemcommunicationantipsychotic medication
QLDcommunity2013-11-11

Pollini, Brett Andrew

43y · Male·Hanging

… patients with bipolar disorder, especially during life stressors. Early intervention and continuity of psychiatric care could have mitigated risk.

psychiatrypsychologycommunicationsystemsodium valproate
VICmental health2012-05-17

Finding into death of Peter Robin Tully

55y · Male·Hanging

Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week be…

psychiatryemergency medicinecommunicationsystemvenlafaxine
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…

psychiatrygeneral practicediagnosticsystemmethylphenidate

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