Coronial

346 results for mental health distress

TASmental health2021-05-21

Coroner's Finding: Hanson, Sungwaan

64y · Female·stage IVB metastatic adenocarcinoma of the rectum

… metastatic adenocarcinoma of the rectum at the Roy Fagan Centre on 27 May 2020. She had been subject to a Mental Health Act treatment order at the time of her death. A rectal mass was identified on examination in Novemb…

psychiatrygeneral medicine
VIC2011-11-23

Finding into death of Tyler Cassidy

15y · Male·Gunshot wound to the chest

Tyler Cassidy, a 15-year-old boy, was fatally shot by Victoria Police on 11 December 2008 during a mental health crisis. He had stolen two large kitchen knives from Kmart and made threatening statements, explicit…

emergency medicinecorrectional healthcommunicationsystemalcohol
NSWhome2016-11-24

Inquest into the death of Dr Beta Vandeville

46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose

…monitoring of restricted drug storage in hospitals, recognition that medical practitioners struggling with mental health may be at risk of substance misuse, and the importance of early intervention when colleagues show s…

anaesthesiaobstetricssystempropofol
NSW2021-10-22

Inquest into the death of A

34y · Male·hanging

A 34-year-old man died by hanging in a correctional centre in December 2018. He was placed on a mental health waitlist in June 2018 but was never seen by a mental health nurse due to insufficient staffing—only…

forensic medicinepsychiatrycommunicationsystem
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

…rms licence by his treating psychiatrist following only two post-attempt appointments, despite documented distress about licence suspension and preoccupation with reinstatement. Risk reduction strategies discussed (secur…

psychiatrygeneral practicediagnosticsystemmethylphenidate
VIChospital2017-12-07

Finding into death of Waisele Qalubau

39y · Male·Complications of large bowel pseudo-obstruction

A 39-year-old man with schizo-affective illness, hepatic cirrhosis, and substance abuse history died from complications of large bowel pseudo-obstruction with aspiration pneumonia. He had been admitted involuntarily for …

psychiatrygastroenterologyclozapine
VIChospital2023-10-30

Finding into death of K K

40y · Male·Full thickness burns to body in the setting of self-immolation

…rary to policy; KK was arrested and physically restrained without clear communication causing significant distress; during police interview, KK was not adequately educated about civil and criminal family violence process…

emergency medicineplastic and reconstructive surgerycommunicationsystemmorphine
WA2019-07-11

Inquest into the Death of Annabel NICOL

50y · Female·ligature compression of the neck (hanging)

…deation who had made a previous hanging attempt and ingested cleaning products. The coroner found that her mental health care was of a high standard within resource constraints, but identified systemic failures: the Cris…

psychiatrycorrectional healthsystemdelaymirtazapine
VIC2022-05-17

Finding into death of Cameron Richard Plant

52y · Male·hanging

…, aged 52, died by hanging in hotel quarantine on 11 April 2020. This case highlights critical failures in mental health screening, welfare monitoring, and escalation procedures. Recent personal stressors (marital separa…

systemcommunication
NSWcommunity2019-05-29

Inquest into the death of Dean WALLIS

46y · Male·Undetermined

…ced decomposition. Dean had a history of alcohol abuse, cannabis use, social isolation, and psychological distress following multiple losses (grandmother's death, pet's death, homelessness). He made concerning remarks ab…

SAhome2024-06-19

Coroner's Finding: Muller, Simon David

46y · Male·acute neck compression due to hanging

… on 10 June 2021 while on home detention bail. He had been unemployed since 2017 and had no known previous mental health diagnoses or suicide attempts. Drug testing on 9 June 2021 returned positive results for amphetamin…

communicationdelayamphetamine
QLDmental health2020-06-29

Rangi, Taare Tamakehu

44y · Male·Cardiac arrhythmia during physical restraint

…-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely sedate him with in…

psychiatryemergency medicinediagnosticprocedurallorazepam
VIChospital2025-10-13

Finding into death of David Greville Edward Horne

47y · Male·Unascertained; most likely cardiac arrhythmia possibly triggered by obstructive …

…roondah Hospital while under compulsory psychiatric treatment. He experienced two episodes of respiratory distress on 5 and 8 December 2023, likely exacerbated by sedative medications (benzodiazepines and antipsychotics)…

psychiatryrespiratory medicinediazepam
QLDhome2007-07-13

Aldred, Belinda Jayne

19y · Female·Death by hanging

…determined death was caused by hanging. Evidence indicated she was last seen on 17 October 2004 appearing distressed after a weekend of heavy alcohol and suspected drug use. The coroner found no evidence of foul play, wi…

forensic medicinetoxicology
SAmental health2007-02-22

Coroner's Finding: CULO John

44y · Male·multiple injuries sustained when struck by a semi-trailer as a result of suicide

…-year-old man with chronic bipolar disorder and severe depression died by suicide while detained under the Mental Health Act at a psychiatric hospital. He was hit by a semi-trailer after absconding from an open ward. The…

psychiatrychlorpromazine
TASmental health2023-03-07

Coroner's Finding: Culic, Jana

35y · Female·neck and chest injuries and drowning due to intentional fall/jump from Tasman Br…

Jana Culic, aged 35, died by suicide jumping from the Tasman Bridge on 4 June 2020 while subject to a Mental Health Act treatment order for schizophrenia, borderline personality disorder, and bipolar disorder. She h…

psychiatryemergency medicinemethamphetamine
WA2023-03-06

Inquest into the Death of Tony Wayne KENNEDY

52y · Male·Multiple injuries

…owing promotion to a supervisor role, was withdrawn and not sleeping well, but declined to seek medical or mental health assistance despite encouragement from his partner. Police responded within approximately 5 minutes …

NSW2020-08-26

Inquest into the death of Tane Chatfield

22y · Male·hypoxic ischaemic encephalopathy as a result of hanging

…ptic by the treating doctor who recommended EEG and specialist review. Upon return to custody, the Justice Health Nurse Unit Manager provided inadequate clinical assessment, failed to obtain the discharge summary, and di…

emergency medicineneurologydiagnosticcommunicationparacetamol
QLDhospital2017-04-04

Coolwell, Bradley Karl

39y · Male·respiratory failure and cardiac arrest

…dministration. Despite these serious findings suggesting respiratory compromise, he was transferred to the mental health ward where acute medical support was unavailable. During admission processes there, he was placed i…

emergency medicinepsychiatrydiagnosticcommunicationmidazolam
NT2019-05-07

Inquest into the death of Sean Daniel Collins

32y · Male·self-inflicted hanging

…certainty, no family or local support, no consular assistance, and severe depression with anxiety. Top End Health Service provided minimal psychiatric care with brief consultations (3-31 minutes), insufficient history-ta…

general practicepsychiatrydiagnosticcommunicationsertraline
156718

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