Coronial

304 results for chronic suicide risk

VICaged care2022-08-01

Finding into death of Mr CLX

85y · Male·Incised wounds to the wrist

…rts. The coroner found care was appropriate given his circumstances. However, the case highlights gaps in suicide risk assessment and mental health support for palliative and aged care patients. Clinical lessons include…

palliative caregeriatric medicinesystemcommunicationoxycodone
WAcommunity2022-08-17

Inquest into the Death of Quoc Xuan TRAN

36y · Male·Immersion (drowning)

…ent to hostel living. He presented to the ED on 8 April 2019 with accommodation concerns; staff conducted a risk assessment documented as non-urgent with no acute mental health issues identified. The coroner found approp…

psychiatryemergency medicinesystempaliperidone
SAhome2007-03-30

Coroner's Finding: LYND Darrell James

37y · Male·hypoxic ischaemic encephalopathy secondary to hanging

…tic relationships, little could have prevented the outcome. The case highlights the challenge of managing suicide risk in individuals with antisocial personality traits who are reluctant to engage with mental health ser…

psychiatryemergency medicineantidepressant medication
TAShome2018-02-05

Coroner's Finding: Dunk, Michael & Johnson, Elishka

Unknown·Michael William Dunk: gunshot wounds to upper abdomen and head. Elishka Dawn Joh…

…partner Elishka Dawn Johnson (41) on 8-10 April 2015 at their Tasmanian property. Ms Johnson then died by suicide using exhaust gas inhalation combined with sedative drugs. Ms Johnson had been treated for depression in …

forensic medicinegeneral practiceoxazepam
VIChome2010-04-27

Finding into death of David Mathew Smith

32y · Male·plastic bag asphyxia

David Mathew Smith, 32, died by plastic bag asphyxia on 25 November 2007. He had schizophrenia, chronic motor tic disorder, sexual paraphilia, and a history of explosive-making offences. He was subject to conc…

psychiatryforensic medicinemedicationcommunicationrisperidone
VIC2024-10-14

Finding into death of Scott Alan Murdoch

43y · Male·Amitriptyline toxicity

Scott Alan Murdoch, a 43-year-old maximum-security prisoner with chronic suicidal ideation, borderline personality disorder, and a documented history of medication hoarding and o…

psychiatrycorrectional healthmedicationsystemamitriptyline
TAShome2023-07-24

Coroner's Finding: QD de-identified

45y · Female·combined drug (tapentadol, nortriptyline, venlafaxine, codeine, oxycodone, queti…

…e, quetiapine, and paracetamol with alcohol. The coroner classified the death as misadventure rather than suicide. Clinical lessons include: GPs prescribing high-risk opioids must conduct regular risk-benefit assessment…

general practicepsychiatrydelaysystemtapentadol
NSW2025-03-24

Inquest into the death of HC

64y · Female·Unascertained

A 64-year-old woman with chronic pain from multiple joint replacements, significant depression following her daughter's death in 2006, and…

VIC2010-05-28

Finding into death of Katherine Fiona Walton

47y · Female·insulin overdose

…from insulin overdose in April 2007. She had a complex medical history including hepatitis C, depression, chronic back pain, epilepsy, and substance use issues. After an argument at home on 23 April, she was assessed at…

emergency medicinepsychiatrycommunicationsysteminsulin
VICaged care2025-05-21

Finding into death of Lorraine Joy Wight

77y · Female·Airways obstruction by tissue paper

A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal id…

geriatric medicinepsychiatrycommunicationsystemoxycodone
WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

…a 54-year-old electrician with longstanding mental health issues including depression, ADHD, and previous suicide attempts, disappeared in late January 2022 after entering State Forest near Flint, WA with camping equipm…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
VICaged care2015-03-26

Finding into death of Chang Ying Xu

72y · Female·Hanging

Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression …

general practicegeriatric medicinediagnosticcommunicationbuprenorphine
VICcommunity2024-10-04

Finding into death of T K

18y · Female·Mixed drug toxicity

TK, an 18-year-old woman with borderline personality disorder, chronic suicidality, and a history of childhood trauma, died from mixed drug toxicity following intentional overd…

psychiatrygeneral practicesystemdelaytramadol
TAShome2022-06-20

Coroner's Finding: Williams, Julie Gaye

59y · Female·mixed prescription drug and alcohol toxicity (ethanol, diazepam, fluoxetine, and…

…hiatric history including depression, PTSD, bipolar disorder, and alcohol dependence, with multiple prior suicide attempts. On 9 June 2019, after consuming hidden alcohol and taking prescribed medications (diazepam, flu…

psychiatrygeneral practicealcohol
TAShome2022-10-25

Coroner's Finding: Meyer, Glenn Sturley

45y · Male·mixed drug toxicity

Glenn Sturley Meyer, aged 45, died from mixed drug toxicity on 22 August 2019. He had chronic pain, PTSD, depression and anxiety managed with oxycodone and diazepam. He also had obesity and probable …

general practicepsychiatryoxycodone
VIChome2022-05-20

Finding into death of Mandy Hawkey

51y · Female·Mixed drug toxicity

A 51-year-old woman with longstanding treatment-resistant depression, chronic pain, and suicidal ideation died from mixed drug toxicity. She intentionally overdosed on multiple medica…

general practicepsychiatrymedicationcommunicationflunitrazepam
VICcommunity2023-08-28

Finding into death of Jorgen Bottern

86y · Male·carbon monoxide poisoning

…t criteria, and discharged to community care with daily follow-up planned. Within three weeks, he died by suicide. Key clinical lessons: (1) older men aged 85+ have the highest suicide rate in Victoria—this demographic …

psychiatrygeneral practicesystem
VIC2016-11-22

Finding into death of Mahmoud Taiba

36y · Male·Hanging

…sis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suicide risk (S4, P3 ratings). While he denied suicidal intent and recent psychiatric reviews were appropriate, t…

psychiatrycorrectional healthcommunicationsystemolanzapine
VIChome2022-01-10

Finding into death of Deborah Marie Holtkamp

52y · Female·Mixed drug toxicity

Deborah Marie Holtkamp, 52, died from mixed drug toxicity in July 2018 in circumstances consistent with suicide. She had a long history of depression, childhood abuse trauma, chronic pain conditions, and recent relati…

general practicepsychiatrydiagnosticcommunicationmorphine
VICcommunity2010-10-19

Finding into death of Patrick Tolan

55y · Male·Multiple injuries sustained in a fall

Patrick Tolan, a 55-year-old man with chronic depression, alcohol dependence, and multiple suicide attempts, died from injuries sustained in a fall fro…

psychiatryorthopaedic surgerydiagnosticcommunicationmirtazapine
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