Coronial

402 results for suicide risk high

SAhome2024-09-13

Coroner's Finding: McKinley-Glen, Haydn James

22y · Male·neck compression due to hanging

…ile under guardianship with special powers of detention in supported independent living. He had attempted suicide by drinking bleach one month prior and was assessed at hospital but not detained. He experienced multiple…

psychiatryemergency medicinepaliperidone
NThome2021-11-25

Inquest into the death of Sammy

9y · Female·suicide by hanging

A 9-year-old Aboriginal girl died by suicide while in out-of-home care. She had been removed from her Aboriginal parents at 10 months of age and place…

paediatricspsychiatrysystemdelaymethylphenidate
VIC2015-03-26

Finding into death of Dalvir Singh

27y · Male·hanging

…-year-old Indian national, died by hanging in immigration detention on 13 February 2014. He had attempted suicide in police custody 16 days earlier but this critical information failed to reach detention centre staff du…

psychiatrygeneral practicecommunicationsystembuprenorphine/naloxone
WAhome2016-02-15

Inquest into the Death of John Stephen PASSMORE

53y · Male·ligature compression of the neck (hanging)

John Stephen Passmore, a 53-year-old man with severe treatment-resistant paranoid schizophrenia, died by suicide while on community leave from psychiatric hospital. He had been an involuntary patient at Graylands Hospi…

psychiatryrehabilitation medicineolanzapine
SAhospital2016-07-13

Coroner's Finding: NOAKES Geoffrey Scott

43y · Male·acute neck compression due to hanging

Geoffrey Noakes, a 43-year-old man with a long history of depression and suicide attempts, was detained under the Mental Health Act on 19 February 2013 after multiple suicide attempts (k…

psychiatryemergency medicinediagnosticcommunicationolanzapine
SA2007-09-19

Coroner's Finding: SMITH Arthur Charles

30y · Male·hanging

…, mood stabilisers), he was discharged from the infirmary to general protective custody on a yellow sheet suicide risk regime. He was found hanging from a metal towel rail in his cell approximately 90 minutes after bein…

psychiatrycorrectional healthsystemcommunicationmirtazapine
VIChome2010-08-23

Finding into death of PC

20y · Male·pulmonary oedema due to acute on chronic heart failure resulting from dothiepin …

…was prescribed dothiepin 300mg daily by a psychiatrist—well above the recommended maximum of 200mg—and this high dose was continued for five months after becoming ineffective. Key clinical failures included: absence of d…

general practicepsychiatrydiagnosticmedicationdosulepin
VIC2023-09-14

Finding into death of Darren Ricky Culleton

31y · Male·Hypoxic ischaemic encephalopathy following out of hospital cardiac arrest in a m…

…his neck (self-harm), was then dressed in coveralls (worn backwards, placing hood at throat) over which a suicide-resistant gown was placed. While awaiting transfer to the Melbourne Custody Centre, he ingested the cover…

emergency medicinepsychiatrycommunicationsystemmethamphetamine
TASmental health2020-10-09

Coroner's Finding: Le Roy, Carole Ann

40y · Female·hypoxic encephalopathy due to asphyxia from hanging

…eation was admitted to an open psychiatric unit after expressing suicidal intent. Despite being assessed as high-risk with a management plan requiring hourly observations, she was placed in an open unit rather than high-…

psychiatryintensive carediagnosticsystem
NSWmental health2015-07-14

Inquest into the death of DA

34y · Male·Neck compression due to hanging

A 34-year-old man with a history of polysubstance abuse, high alcohol intake, and a recent suicide attempt died by hanging six weeks after being admitted to mental healt…

psychiatryemergency medicinediagnosticcommunicationmirtazapine
QLDcommunity2015-06-09

JE and JJ, two 16 year old boys

16y · Male·Hanging (ligature compression of neck)

…o Indigenous young men, JE (16 years) and JJ (16 years), both died by hanging within four months during a suicide cluster in Mackay, Queensland in 2008. JE's death was impulsive, occurring after paint sniffing and alcoh…

psychiatryemergency medicinediagnosticcommunicationalcohol
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
VICmental health2022-12-21

Finding into death of Kai Wesley Wu

23y · Male·Injuries sustained when struck by train

Kai Wu, a 23-year-old man with first-episode psychosis, died by suicide at a railway station while on escorted leave from psychiatric inpatient care. He had been admitted to The…

psychiatrycommunicationsystemhaloperidol
VIChome2026-01-06

Finding into death of Michelle Margaret Darragh

32y · Female·Stab wound to the back extending into the posterior neck, causing subtotal trans…

…ive jealousy, and controlling behaviours, though no prior physical violence occurred. Coman had attempted suicide days before the homicide after the relationship ended. Eastern Health admitted Coman to the mental health…

psychiatryemergency medicinediagnosticcommunicationsertraline
VIC2024-10-14

Finding into death of Scott Alan Murdoch

43y · Male·Amitriptyline toxicity

… cell door trap. Key clinical lessons include: tricyclic antidepressants pose substantial overdose fatality risk in high-risk patients and safer alternatives should be prioritised; medication supervision through cell tra…

psychiatrycorrectional healthmedicationsystemamitriptyline
VICcommunity2024

Finding into death of E K

43y · Male·multiple injuries in a train incident

A 43-year-old man died by suicide after being notified by police of sexual assault allegations via telephone. He placed himself in front of…

communicationsystem
TAShome2023-06-19

Coroner's Finding: Dawson, Andrew

44y · Male·Methamphetamine toxicity

…is home in Leith, Tasmania. He had a history of depression, anxiety, heavy illicit drug use, and a recent suicide attempt by overdose in September 2021. Following relationship distress and suicidal text messages, he lik…

methamphetamine
VIChome2021-02-25

Finding into death of MrP

24y · Male·Gunshot wound to the head

…n with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treating psychiatrist …

psychiatrygeneral practicediagnosticsystemmethylphenidate
VICcommunity2024-08-29

Finding into death of Bridget Flack

28y · Female·compression of the neck and hanging

…lex mental health issues including depression, anxiety, borderline personality disorder and PTSD, died by suicide in December 2020 after becoming increasingly isolated during COVID-19 lockdowns and experiencing relation…

psychiatrypsychologycommunicationsystemescitalopram
NSW2022-10-24

Inquest into the death of GL

69y · Male·neck compression due to hanging

…est found his death was intentionally self-inflicted by hanging using bed mechanisms. Clinically, this case highlights the challenge of suicide risk assessment in older prisoners with complex trauma, language barriers, a…

psychiatrygeriatric medicine
156721

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