Coronial

308 results for family crisis

NThome2001-01-25

Inquest into the death of Eduardo Concepcion

26y · Male·multiple gunshot wounds with death resulting from combination of blood loss and …

Eduardo Concepcion, a 26-year-old man experiencing mental health crisis and acute intoxication, died from multiple gunshot wounds inflicted by Northern Territory Police. Followin…

emergency medicinepsychiatrysystemcommunicationmogodons
NSWcommunity2025-11-03

Inquest into the death of JF

60y · Female·multiple injuries

JF, a 60-year-old woman with recurrent major depressive disorder and a history of suicide attempts, died by suicide at Redhead Headland on 12 February 2024. Despite three prior psychiatric hospitalizations and documented…

psychiatrygeneral practicesystemmirtazapine
NSWcommunity2025-09-18

Inquest into the death of Hillal Barbour

29y · Male·gunshot wound to the chest

…s significantly increases risk. Better pre-hospital information systems and consideration of mental health crisis teams might have assisted earlier intervention, though likely could not have changed the acute encounter o…

psychiatryemergency medicinecannabis
NSW2017-07-11

Inquest into the death of LP

72y · Male·multiple injuries resulting from catastrophic head injury with massive disruptio…

…ng centre. He had stopped taking prescribed medications and had been planning this action, making calls to family members beforehand stating his intention. Police negotiators arrived within minutes and attempted engageme…

psychiatrycorrectional health
NT2008-10-10

Inquest into the death of Rebecka Hans

18y · Female·Gunshot wound to the head

Rebecka Hans, a 18-year-old woman, died from a self-inflicted gunshot wound to the head while police negotiators attempted to engage her at her Darwin River residence. She had called police early on 24 October 2007 expre…

VIChome2014-07-18

Finding into death of Shyra Lee Bloomfield

16y · Female·hanging

A 16-year-old Aboriginal girl died by hanging after an episode of inhalant ('chrome') use and relationship breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement …

paediatricsaddiction medicinesystemcommunicationinhalant
VIChome2024-10-07

Finding into death of Suzanne Norah Evans

50y · Female·Combined drug toxicity in a woman with tension pneumothorax

Suzanne Evans, aged 50, died from combined drug toxicity in the setting of tension pneumothorax. She had a history of alcohol dependence, depression, and borderline personality disorder. Following an argument with her pa…

emergency medicinetoxicologybaclofen
VIChome2015-01-28

Finding into death of Anthony Gerard Mooney

46y · Male·acute strychnine poisoning

Anthony Gerard Mooney, 46, died from acute strychnine poisoning on 7 September 2008. The coroner found he deliberately self-administered the poison to end his life. Mr Mooney was a builder facing severe financial difficu…

strychnine
SAhome2025-03-31

Coroner's Finding: Constantine, Matthew Keith

33y · Male·hypoxic-ischaemic encephalopathy due to hanging with resuscitation

Matthew Keith Constantine, aged 33, died from hypoxic-ischaemic encephalopathy following a hanging attempt while under home detention. He was released from prison in December 2021 with parole conditions including electro…

intensive careemergency medicinemethamphetamine
VIChome

Finding into death of Jarrad John Ford

24y · Male·Aspiration pneumonia secondary to drug abuse and overdose of multiple drugs

…down mental health facilities meant the patient remained at home under inadequate observation during acute crisis. The coroner recommended funding for intermediate mental health facilities in the Latrobe Region to bridge…

psychiatryemergency medicinediagnosticsystemdiazepam
NSWhome2023-04-26

Inquest into the death of Trudy Michelle Dreyer

49y · Female·Multiple shotgun wounds to the chest and back of head

…ner during a domestic incident on 19 September 2019. The couple had relationship difficulties and attended family support services in July 2019, where counselling focused on communication and de-escalation strategies. Te…

VICcommunity2014-02-07

Finding into death of Bayden Joel Quilkey

30y · Male·unascertained

…n gathering from the referrer, proactive follow-up within 18-24 hours, better staff handover, and treating family callers as clients requiring support with advice on symptom recognition and engagement strategies. Police …

psychiatryemergency medicinesystemcommunication
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

…cal lessons: the referring psychiatrist's management plan to the GP lacked detail regarding warning signs, crisis management, medication compliance strategies, and follow-up frequency; responsibility for ongoing care was…

psychiatrygeneral practicecommunicationsystemolanzapine
NSW2022-10-28

Inquest into the death of Todd McKenzie

Male·Consequences of police tactical operation involving use of lethal force (specifi…

… clinical-adjacent lessons include the importance of obtaining mental health background information before crisis response, considering psychiatric consultation availability, and ensuring adequate negotiation team prepar…

emergency medicinecorrectional healthsystem
NSWcommunity2023-11-07

Inquest into the death of DO

27y · Male·multiple blunt force injuries

…ied by suicide four days after arriving in Australia. He had disclosed suicidal ideation to his friend and family on 24 November, was recovered from a cliff edge that evening, but died the following night after jumping f…

VICcommunity2012-03-01

Finding into death of K

33y · Male·complications from blunt force trauma to head consequent upon being struck by a …

…se and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm and concluded he was not suicidal, diagnosing drug…

psychiatrygeneral practicediagnosticcommunicationmethadone
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

…communication was unclear, no comprehensive management plan was provided addressing compliance strategies, crisis planning, or warning signs of deterioration. Mrs Beck began self-adjusting medication dosages without medi…

psychiatrygeneral practicecommunicationsystemolanzapine
VIChome2018

Finding into death of Catherine Louise Haley

29y · Female·Blunt force injuries to the head

…ead and face, causing severe blunt force injuries. The coroner noted this death occurred in the context of family violence and highlighted the difficulty third parties face in intervening. The case underscores the import…

forensic medicine
WAcommunity2005-11-04

Inquest into the Death of Sheridan Troy Hilton

42y · Female·Ligature compression of the neck (hanging)

…ntley Psychiatric Hospital on 21 August. Although assessed as a voluntary patient with protective factors (family support, stated unwillingness to self-harm), she was discharged on 26 August against medical preference du…

general practicepsychiatrycommunicationsystemmirtazapine
SAhome2014-01-31

Coroner's Finding: HADLEY Duke Zenon

2y · Male·Asphyxiation due to neck and/or chest compression

…emic failures including inadequate follow-up, premature file closure due to resource constraints, and poor crisis response contributed to missed opportunities for intervention. The coroner identified under-resourcing, la…

psychiatryemergency medicinecommunicationsystemrisperidone
156716

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