Coronial

273 results for acute mental illness

VIChome2021-12-06

Finding into death of Daniel Charles Richards

48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male

Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hyp…

psychiatryemergency medicinesystemcommunication
VICcommunity2025-08-27

Finding into death of Harley James Smith

7y · Male·multiple injuries sustained in a motor vehicle collision (passenger)

…ould have prompted intervention to prevent this tragedy. The case highlights the challenges in identifying acute suicide risk in distressed individuals and the importance of comprehensive family support during terminal …

paediatricspsychiatrycommunicationsystemmirtazapine
TAScommunity2022-01-28

Coroner's Finding: AZ 2022 TASCD 60

16y · Male·Multiple blunt traumatic injuries from fall from height

A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had p…

psychiatrycommunicationdiagnosticfluoxetine
WAcommunity2021-07-23

Inquest into the Death of Dean Jesse GERRARD-LATHAM

24y · Male·Environmental exposure in a man with methylamphetamine effect

Dean Jesse Gerrard-Latham, a 24-year-old Indigenous man, died from environmental exposure while acutely intoxicated by methylamphetamine in bushland near Derby, WA. After evading police i…

forensic medicineemergency medicinedelaymethamphetamine
SAhospital2005-08-11

Coroner's Finding: BEGBIE Peter John

41y · Male·multi-organ failure and staphylococcal septicaemia following pulmonary and aorti…

…to RAH. He absconded after 24 hours, returning to the community in a delirious state due to sepsis-induced acute organic brain syndrome. He was appropriately detained under the Mental Health Act to ensure treatment, re-…

cardiothoracic surgerygeneral medicinediagnosticantibiotics
VICaged care2015-05-18

Finding into death of Krizan Vuksan

75y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis; acute myoc…

…an Vuksan, a 75-year-old man with chronic schizophrenia, hypertension, and cardiac risk factors, died from acute myocardial infarction secondary to ischaemic heart disease while residing in a mental health aged care fac…

psychiatrygeneral practicecommunicationsystemolanzapine
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds

…etamine toxicity after consuming 2 grams of ice. Despite referral to psychiatry, he did not follow up with mental health services after discharge. On the day of death, during a delusional episode exacerbated by methamphe…

psychiatryemergency medicinedelaymethamphetamine
WA2019-01-07

Inquest into the Death of Ali JAFFARI

Male·thermal injuries (burns)

…. The deceased had attempted self-harm twice previously (August and September 2015) and received extensive mental health support through the Psychological Support Program, including psychiatric review and monitoring. He …

psychiatrypsychologysystemolanzapine
WAhome2004-06-04

Inquest into the Death of Paul John Long

37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion

…37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in May 2002 homeless…

psychiatrygeneral practicecommunicationsystemquetiapine
WAhospital2024-04-05

Inquest into the Suspected Death of Neil Lindsay KOBELT

27y · Male·unascertained

…disappeared from Kalgoorlie, Western Australia in February 1982, shortly after discharge from hospital for acute psychiatric crisis. He had relocated to Western Australia to avoid compulsory medication in South Australi…

psychiatrygeneral medicinecommunicationsystem
NSW2015-11-11

Inquest into the death of W

23y · Male·Hanging whilst suffering acute mental illness, most likely a first episode delus…

…d suicidal ideation on 20 April and was assessed by a Risk Intervention Team. Despite being diagnosed with acute mental illness and paranoid delusions on 2 May, he was placed on a waiting list for the Mental Health Scre…

psychiatrycorrectional healthdiagnosticcommunication
QLDcommunity2018-09-11

Giorgio, Pasquale

54y · Male·Ischaemic cardiomyopathy following a period of restraint on a background of morb…

…PR until a senior officer arrived. Clinical experts noted officers lacked sufficient training to recognise acute medical deterioration in this context. Earlier removal from the van and immediate CPR initiation may not h…

emergency medicineforensic medicinediagnosticcommunicationflupenthixol
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

…death of her long-term partner and de facto father of her children. Critical clinical lessons include: (1) Mental health clinicians must ensure immediate assessments occur when patients present with acute psychotic sympt…

psychiatryemergency medicinedelaycommunicationclozapine
WAcommunity2022-06-09

Inquest into the Death of Desmond Edward JACK

33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)

…Harrison on 28 March 2019. Jack had deteriorated significantly over preceding days despite engagement with mental health services; he had refused voluntary hospital admission despite his mother's concerns. When police at…

psychiatryemergency medicinesystemmirtazapine
QLDcommunity2023-04-05

Grimes, William George

31y · Male·Burns

…0% body surface area burns and died 7 days later. Clinical lessons include: police recognition of critical mental health risk with lethal means; gaps in mental health safety planning that failed to involve family despite…

psychiatryemergency medicinediagnosticcommunicationquetiapine
VICmental health2015-10-15

Finding into death of Helen Maria Bryce

54y · Female·Hanging

…vere depression and anxiety in early 2011. After two suicide attempts, she was admitted to Austin Health's Acute Psychiatric Unit involuntarily. After 11 days of treatment and progressive day leave, she was approved for…

psychiatrygeneral practicecommunicationsystemcitalopram
VICmental health2011-05-17

Finding into death of Ralph Graeme Keat

64y · Male·unascertained natural causes

…alph Keat, a 64-year-old man with frontal lobe dementia, was admitted to Kingston Centre as an involuntary mental health patient on 12 April 2010. On 14 April, he was found unresponsive in the bathroom and could not be r…

psychiatrygeriatric medicinetemazepam
WAmental health

Inquest into the Death of David GRIEVE

45y · Male·Coronary Atherosclerosis

…r Charles Gairdner Hospital 11 days before death with palpitations and dyspnea, attributed to psychiatric illness after cardiac investigations appeared normal. During his final psychiatric admission, his general medical…

psychiatrycardiologysystemcommunicationhaloperidol
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

…ly in 2020 via DNA), and inadequate policy frameworks. The case demonstrates how poor coordination between mental health services, university pastoral care, social work, and law enforcement can allow vulnerable foreign s…

psychiatrypsychologysystemcommunicationantipsychotic medication
NSW2024-08-22

Inquest into the death of Russell Zaska

33y · Male·hanging

Russell Zaska, a 33-year-old man with a complex mental health history including probable methamphetamine dependence and recurrent drug-induced psychosis, died by…

psychiatrycorrectional healthsystemdelayolanzapine
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