Coronial

149 results for attempted suicide

VICcommunity2017-08-25

Finding into death of Steven John Dows

43y · Male·Multiple injuries sustained in a motor vehicle incident (driver)

… speed (>100 km/h) and crossed into the southbound lane where Mr Dows was travelling at 80 km/h. Mr Dows attempted evasive action but could not avoid the collision due to terrain and proximity to trees. The coroner inve…

forensic medicinepsychiatry
SA2003-12-18

Coroner's Finding: LINDSAY Margaret

38y · Female·neck compression due to hanging

…manded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite comprehensive documentation from police identifying her as suicidal, at-risk, and recen…

psychiatrycorrectional healthcommunicationsystemdiazepam
VICinpatient2016-03-03

Finding into death of TK

18y · Female·Hypoxic brain injury secondary to hanging

An 18-year-old woman with major depressive disorder and PTSD was admitted to a psychiatric inpatient unit after expressing suicidal ideation and self-harm. She was changed from involuntary to voluntary status after clini…

psychiatryintensive caresystemcommunicationfluoxetine
QLD2011-12-09

Inglis, Tracey Lee

37y · Female·exsanguination from incised wounds to right wrist and elbow

…chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial Risk and Needs Assessment failed to iden…

psychiatrygeneral practicediagnosticcommunicationparacetamol/codeine
NSW2024-03-06

Inquest into the death of WM

59y · Male·Hanging

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 r…

psychiatryforensic medicinesystemmirtazapine
SA2009-05-19

Coroner's Finding: O'KEEFFE Daniel William Barry

34y · Male·hypoxic encephalopathy following hanging

… died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody after his bail was revoked for breaching conditions. Although appropriately i…

psychiatryintensive caresystemcommunicationcitalopram
WAhospital2022-01-25

Inquest into the Death of Carole LIVESEY

54y · Female·unascertained

… in hospital grounds. She had been an involuntary patient admitted on 7 September 2017 following multiple suicide attempts. Though found wet and distressed (suggesting attempted drowning) by the Salvation Army, police f…

psychiatrygeneral medicinecommunicationproceduralfluoxetine
TAShome2018-07-06

Coroner's Finding: Godley, David Geoffrey

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

…ing a delusional episode exacerbated by methamphetamine use, he inflicted fatal self-harm while his wife attempted to stop him. The coroner found no preventable clinical failures but noted the significant role of chroni…

psychiatryemergency medicinedelaymethamphetamine
QLD2024-05-13

HARVEY, Thompson

33y · Male·Neck compression (hanging)

…pricornia Correctional Centre on 13 November 2017, four days after remand for serious offences including attempted murder. He had a recent suicide attempt by gunshot wound (31 October), was on opiate medications for wit…

psychiatrypsychologycommunicationdiagnosticmorphine
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…

psychiatryemergency medicinediagnosticcommunicationquetiapine
VIChome2011-09-13

Finding into death of Rosa Sinapi

47y · Female·risperidone toxicity

…m 3mg to 6mg daily without medical advice. On 16 October 2009, her GP recognised acute deterioration and attempted urgent referral to mental health services but encountered significant system barriers: geographical catc…

psychiatrygeneral practicesystemdelayrisperidone
VIChome2015-11-30

Finding into death of Nidhi Parashar

29y · Female·Hanging

…s Parashar in November 2010, resulting in an intervention order and criminal conviction. Ms Parashar had attempted to divorce him but was deterred by cultural stigma and lack of formal documentation. She obtained an int…

forensic medicinepublic healthsystem
VICmental health2022-06-29

Finding into death of Melissa Gaultier

34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…

…il 2017, while on approved leave, she absconded from a visitor and was found in circumstances suggesting attempted suicide. She was eventually reported missing; police conducted searches overnight. The next morning she …

psychiatryobstetricscommunicationdiagnostic
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

…comprehensively explore patients' reasons for sudden discharge requests, inadequate risk assessment after suicide attempts, poor liaison with family support systems, and lack of assertive follow-up within 24 hours of di…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

… 31 July with active suicidal ideation, paranoia, and psychotic symptoms. A triage nurse (Marcelle Rust) attempted to assist but lacked legal authority to detain him. The hospital referred the case to the Armadale Commu…

emergency medicinepsychiatrycommunicationsystemamphetamine
QLDcommunity2017-09-14

John, Timothy

22y · Male·Hanging

…r smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted suicide. His GP, Dr Y., prescribed Champix without adequately reading product information about neuropsy…

general practicepsychiatrydiagnosticcommunicationvarenicline
NSWhome2022-03-30

Inquest into the deaths of Stacey DOCHERTY and Seth DOCHERTY

38 and 3y · Female and male·Stacey: hanging; Seth: undetermined causes (likely suffocation, drowning, or str…

…ct during a critical period, particularly during a poorly managed caseworker handover. While the homicide-suicide could not have been predicted, earlier multidisciplinary coordination, more robust psychiatric oversight …

psychiatrygeneral practicemedicationcommunicationalprazolam
WAcommunity2023-02-28

Inquest into the Death of Paul James BRADY

35y · Male·multiple injuries

…lice officers arrived at the scene within minutes of receiving a call about a man on a ledge. While they attempted to persuade Mr Brady to sit down, he jumped within approximately four minutes. The officers initially fa…

emergency medicineforensic medicineproceduraldelaytemazepam
SAhospital2004-12-14

Coroner's Finding: O'NEILL Louise Kay

31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)

A 31-year-old woman with extensive history of deliberate self-harm and prescription drug abuse died from mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam). She presented to the emergency department with a r…

emergency medicinetoxicologydiagnosticcommunicationpropoxyphene
NSWmental health2024-05-16

Inquest into the death of Roger Frederick Schnelle

59y · Male·head injuries

…luded: inadequate escalation of nursing observations despite clear warning signs (threatening self-harm, attempted choking, concerning communications with family); lack of multidisciplinary risk formulation and manageme…

psychiatrygeneral practicediagnosticcommunicationsertraline
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