Coronial

142 results for severe chronic depression

WAcommunity2024-10-22

Inquest into the Death of Karl Jonathan TURNER

49y · Male·combined drug toxicity

Karl Turner, a 49-year-old man with schizoaffective disorder and chronic polysubstance use, died from combined drug toxicity (heroin, morphine, pregabalin, methylamphetamine, and…

psychiatryintensive caresystemdelaymorphine
VIChospital2016-08-26

Finding into death of Alan William Worrall

47y · Male·Progressive multifocal leukoencephalopathy

…usal connection between custody status and death. The death resulted from natural causes in the context of severe immunosuppression and poor prior treatment adherence.

infectious diseasesgeneral medicineanti-retroviral medications
NSW2011-07-01

Coroner's Finding: Michael Peter Magro

40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…

… a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were identified. On 17 December, Mr. Magro submitted urg…

correctional healthgeneral practicediagnosticcommunicationmethadone
WA2002-05-03

Inquest into the Death of Gerhardus Theron

39y · Male·Ligature Compression of the Neck (Hanging)

… on 28 April 2000 while their four children were present, and was remanded in custody. He presented with depression and suicidal risk which was managed through restrictive environments initially. By 21-22 June, health pr…

psychiatrycorrectional healthsystemanti-depressants
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

…uest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered wi…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
ACTaged care2003-08-04

Inquest Into The Manner And Cause Of Death Of Ivy Pearl Ghobrial

Female·bilateral acute bronchopneumonia

…y sustained from a hanging attempt in March 2000. The coroner found the death resulted inevitably from her severe irreversible brain injury. Medical teams correctly determined that invasive interventions for recurrent as…

psychiatryneurology
QLDhospital2010-10-29

Spence, Samantha Rose

12y · Female·Raised intracranial pressure due to acute-on-chronic hydrocephalus in the contex…

Samantha Rose Spence, 12 years old, died two days after spinal fusion surgery for severe scoliosis. She had a pre-existing, asymptomatic Chiari type 1 malformation detected on pre-operative MRI o…

orthopaedic surgeryneurologydiagnosticcommunicationmorphine
SAcommunity2005-03-14

Coroner's Finding: Ryan Kunmanara

Unknown·Multiple; Kunmanara Ward: neck compression due to hanging; Kunmanara Ken: exposu…

…g with evidence of petrol intoxication. Ken (35) died from exposure after wandering away from care; he had severe brain damage from decades of petrol sniffing. Cooper (27) died by hanging after recent release from psychi…

psychiatryemergency medicinedelaysystempetrol
VIChome2026-04-17

Finding into death of Simon Christopher Gaskill

50y · Male·unascertained

…r sleeping rough for months. He had been discharged from hospital in December 2021 following treatment for severe alcohol withdrawal and seizures, sent to homelessness without adequate follow-up care. His cause of death …

emergency medicinegeneral medicinecommunicationsystemalcohol
WAhome2017-03-30

Inquest into the Death of Troy William MURRAY

34y · Male·ligature compression of the neck (hanging)

Troy William Murray, a 34-year-old man with a long history of substance abuse (primarily amphetamine and alcohol), psychiatric illness, and multiple previous suicide attempts, died by hanging on 11 March 2012. He had bee…

psychiatrygeneral practicecommunicationamphetamine
NSWprison2017-03-31

Inquest into the death of Keith HOWLETT

49y · Male·complications of non-small cell carcinoma of the lung

…r 5 weeks of incarceration. He had complex medical needs including HIV, peripheral vascular disease, and depression. The coroner found the transfer of care from community to custody was below best practice. Dr B. did not…

general practiceoncologydiagnosticsystem
NSWmental health2019-02-12

Inquest into the death of Kevin O’Halloran

55y · Male·positional asphyxia, with sedation as an underlying risk factor

Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and poss…

emergency medicinepsychiatrycommunicationproceduralmidazolam
QLDhospital2018-07-30

Khazaei, Hamid

24y · Male·Hypoxic-ischaemic encephalopathy, due to or as a consequence of cardiac arrest, …

…n detention. His death was preventable and resulted from multiple compounding errors: failure to recognise severe sepsis despite worsening vital signs; lack of appropriate antibiotics at the Manus Island clinic; failure …

emergency medicineinfectious diseasesdiagnosticcommunicationceftriaxone
QLDhospital2024-06-21

Non-inquest findings into the death of Mr K

81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…

An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management e…

respiratory medicineemergency medicinemedicationcommunicationdiazepam
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

Devan Ginbey, a 20-year-old with longstanding mental health issues including depression, psychosis, ADHD, and substance abuse, presented to Peel ED on 12 January 2022 with self-harm and active…

emergency medicinepsychiatrysystemdelay
VIChospital2023-03-10

Finding into death of Armin Andrew Schaefer

63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…

…mpromise. The combination of polypharmacy with QT-prolonging agents, airway obstruction, and respiratory depression in a patient with known sensitivity to sedation likely precipitated fatal arrhythmia or asphyxiation. Ke…

psychiatryemergency medicinediagnosticcommunicationdiazepam
VICcommunity2023-07-28

Finding into death of Marcus William Caldwell

27y · Male·Hanging

…enia on clozapine, died by suicide in February 2018. He worked at a pet boarding facility that experienced severe staffing shortages during peak season, resulting in excessive workloads, long consecutive shifts (up to 14…

psychiatrygeneral practicesystemcommunicationclozapine
VIC2026-04-22

Finding into death of Natasha Stojkoski

38y · Female·Multiple injuries sustained when struck by a train

…ng complaint. This mishandling, combined with ongoing physical pain and workplace distress, contributed to severe major depression. Despite attendance at emergency department in March 2021, no adequate psychiatric assess…

psychiatryoccupational and environmental healthsystemcommunicationescitalopram
VIChospital2020-04-16

Finding into death of Jessica Higgins

33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity

Jessica Higgins, a 33-year-old woman with chronic pain on high-dose opioids, underwent ketamine infusion with planned opioid rotation to methadone in May 2…

pain medicineemergency medicinecommunicationdiagnosticmethadone
VIChome2013-09-12

Finding into death of Sarolta Elesits

54y · Female·Acute alcohol toxicity with immersion

A 54-year-old woman with major depressive disorder and alcohol addiction died from acute alcohol toxicity with immersion. She was hospitalised involuntarily on 23 December 2008 with a blood alcohol level of 0.323 and sui…

psychiatryaddiction medicinecommunicationsystemalcohol

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