Coronial

214 results for major depressive disorder

NSWhospital2021-06-11

Inquest into the death of Sam Cain (a pseudonym)

23y · Male·hanging

A 23-year-old male with treatment-resistant schizophrenia died by hanging while an involuntary patient in the High Dependency Unit of Royal North Shore Hospital. He presented acutely on 4 February 2019 with severe suicid…

psychiatryemergency medicinecommunicationsystemaripiprazole
TAShome2018-02-28

Coroner's Finding: Evans, Jillian and John

62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs …

…was admitted to Launceston General Hospital on 17 July after acute deterioration, correctly diagnosed with major depression with psychotic features, and treated with Risperidone. He was transferred to St Luke's hospital…

psychiatrygeneral practicediagnosticcommunicationrisperidone
NSWmental health2020-11-27

Inquest into the death of JP

46y · Female·hypoxic brain injury due to hanging

A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had …

psychiatryemergency medicinecommunicationprocedural
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

…olan House mental health facility in April 2021. He developed sudden onset severe mental illness (anxiety disorder with depressive features, with possible psychotic depression) triggered by debilitating vestibular sympto…

psychiatrygeneral practicediagnosticcommunicationsertraline
VIChome2022-10-06

Finding into death of Ozlem Karakoc

34y · Female·Drowning

… a bathtub. Ms Karakoc had mild intellectual disability, a history of mental illness (depression, bipolar disorder, schizoaffective disorder, PTSD), and had experienced prolonged family violence from Mr Davsanoglu includ…

psychiatrygeneral practicecommunicationsystemvenlafaxine
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

…en 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She was discharged from Shellharbour Ment…

psychiatryemergency medicinesystemclozapine
VIChospital2017-12-14

Finding into death of Craig Michael Akerblom

31y · Male·Hypoxic ischaemic brain injury secondary to hanging

Craig Akerblom, a 31-year-old man with depression, anxiety, substance abuse, and selective eating disorder, died by hanging resulting in hypoxic-ischaemic brain injury. He had been under care of multiple clinicia…

general practicepsychiatrycommunicationsystemvenlafaxine
NSW2011-12-19

Villawoodfindings redacted

Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)

…orating mental health; mental health protocols were not followed, his diagnosis was incorrect (Adjustment Disorder rather than Major Depressive Disorder), and requests for transfer were ignored. David Saunders (UK nation…

psychiatrygeneral medicinediagnosticcommunicationmirtazapine
VIChome2026-03-19

Finding into death of Catherine Alison Lynch

41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…

Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…

psychiatrypsychologycommunicationsystemalprazolam
VIChome2014-05-15

Finding into death of Georgia Susan Cheal

31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…

Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescript…

general practicepsychiatrycommunicationsystemoxycodone
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

Gina Valera, a 49-year-old woman with a history of depression and three prior suicide attempts, died by hanging in Brisbane Women's Correctional Centre nine days after admission on remand for attempted murder. She had be…

psychiatrycorrectional healthcommunicationsystemmirtazapine
NSWcommunity2009-02-27

02anonfinding

54y · Male·Died by hanging while suffering from the effects of Post-traumatic Stress Disord…

A 54-year-old NSW police officer died by suicide while suffering from PTSD and Bipolar Disorder. He had witnessed multiple traumatic incidents during his 25-year career and was diagnosed with Bipolar D…

general practicepsychiatrylithium
NSWhospital2018-04-27

Inquest into the death of Matthew Wilson Leary

25y · Male·drowning

…mized. Treating teams did not obtain collateral histories from the psychologist who had diagnosed him with major depression. Communication protocols for family concerns were inadequate. Discharge decisions proceeded des…

psychiatryemergency medicinediagnosticcommunicationcitalopram
VIChospital2025-09-03

Finding into death of Olivia Alexandra Evans

15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa

…r two years with escalating food refusal, self-harm, and suicidal behaviour. Key clinical lessons: eating disorder services require integrated medical-psychiatric teams; brief admissions without ensuring sustained oral e…

psychiatrypaediatricsdiagnosticsystemparacetamol
TAScommunity2019-12-06

Coroner's Finding: McInerney, Robert Edward

48y · Male·gunshot wounds to the right thigh and abdomen with fatal hemorrhage

A 48-year-old man with severe chronic pain, alcohol dependence, and mental health issues called police stating he was armed with knives and wanted to be shot. Despite being extensively supported by health services that d…

psychiatryemergency medicinealcohol
SA2004-08-06

Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

…rison industries area was accessible to prisoners. The coroner emphasised that while Mr Turner had shown depressive symptoms requiring monitoring, the immediate preventable factor was the failure to attempt resuscitation…

psychiatryemergency medicineproceduralsystemfluvoxamine
TAShome2022-11-29

Coroner's Finding: Young, Andrew Robert

61y · Male·hanging

Andrew Robert Young, a 61-year-old man with lifelong depression and social phobia, died by hanging on 13-14 January 2020. He had received consistent psychiatric care from an experienced psychiatrist for 16 years using su…

psychiatrygeneral practicediazepam
VIC2015-11-05

Finding into death of Kasim Colic

79y · Male·Unascertained

A 79-year-old man with vascular dementia, cerebrovascular disease, and a history of violent behaviour was placed under a non-custodial supervision order following a mental impairment finding. Approved leave to visit fami…

psychiatrygeriatric medicinecommunicationsystem
VIChome2025-03-14

Finding into death of Jonathan Mark Townsend

59y · Male·Unascertained

Jonathan Townsend, a 59-year-old Navy veteran with PTSD, alcohol use disorder, and multiple psychiatric comorbidities, died at home on 5 November 2021. The cause of death was unascert…

trauma surgerypsychiatrycommunicationsystemdiazepam
NSWhome2026-03-04

Inquest into the death of BX

29y · Male·Gunshot wound to the head, self-inflicted

BX, aged 29, died from a self-inflicted gunshot wound to the head on 17 July 2023 during a police siege at Bowenfels, NSW. Following a domestic violence incident report, police arrived and BX refused entry, triggering a …

communicationsystem
156711

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