Coronial

308 results for family crisis

QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…

psychiatryemergency medicinecommunicationsystemmethamphetamine
QLD2008-03-17

Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael

gunshot wounds; multiple deaths during police interventions with mentally ill in…

…ebruary 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the officers reasonably believed th…

psychiatryemergency medicinediagnosticcommunicationantipsychotic medications
QLDhome2006-07-07

Hooymans, Kylie Danielle

24y · Female·asphyxiation due to hanging

…sionally and that home-based care was clinically appropriate. However, the coroner identified that Kylie's family lacked awareness and training regarding the interrelationship between different mental health services inv…

psychiatrycommunicationsystem
VIChospital2025-04-14

Finding into death of Joshua Gonzalez

35y · Male·Neck compression due to hanging

…t and tailor follow-up. The coroner recommended developing structured handover protocols for mental health crisis transfers and improving access to mental health databases for emergency clinicians.

emergency medicinepsychiatrycommunicationsystemalcohol
VIChome2021-12-06

Finding into death of Daniel Charles Richards

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

…ventricular hypertrophy and old myocardial infarction. A CAT team assessment order was initiated after his family contacted mental health services. When police assisted with the order, Danny resisted vigorously during a …

psychiatryemergency medicinesystemcommunication
SA2008-12-03

Coroner's Finding: WHEATON Rowan Scott

18y · Male·neck compression due to hanging

… chronic suicide risk, poor medication compliance without enforcement mechanisms, missed opportunities for crisis intervention in final weeks, and pressure to discharge from inpatient units without adequate community inf…

psychiatryemergency medicinediagnosticcommunicationcitalopram
NThome2011-03-15

Inquest into the death of Dwayne Joseph Berto

23y · Male·Suicide by hanging

… was highly intoxicated (blood alcohol 0.268%) and deeply distressed. Contributing factors included recent family separation, arguments with his father about a car purchase, relationship difficulties, and a humiliating p…

psychiatryemergency medicinealcohol
NSWhome2015-06-19

Inquest into the death of Matthew THOMAS

31y · Male·gunshot wounds to the head and chest

…n rather than a medical or clinical matter. However, the coroner identified a systemic failure: the Thomas family was not clearly informed that they would be responsible for crime scene forensic cleaning costs, leading t…

QLDcommunity2013-03-15

Morgan, Charles Ross Maxwell

18y · Male·Multiple injuries due to train over-run

…uding substance abuse and impulsive aggression. However, he appeared happy to friends that evening and had family support. Key clinical lesson: young people with substance abuse, relationship instability, and aggressive …

psychiatrypsychologycommunicationsystemalcohol
TAScommunity2024-04-11

Coroner's Finding: de-identified CR

52y · Male·fully suspended hanging

A 52-year-old man died by fully suspended hanging following a series of acute stressors. He had a history of ischemic heart disease and was on antidepressant medication. A critical precipitant was an early morning AFP se…

duloxetine
VIChospital2025-07-03

Finding into death of JV M

19y · Female·multiple injuries sustained in a train incident

…ntal Health Service (SVHM) in the week before her death. Key issues identified: inadequate engagement with family despite their expressed concerns about escalating suicidal ideation; incomplete safety planning that did n…

psychiatryemergency medicinecommunicationsystemsertraline
NThospital2010-08-11

Inquest into the death of Gottlieb Rubuntja

39y · Male·coronary atherosclerosis

…ronary atherosclerosis after police responded to reports of strange and agitated behaviour. His mother and family had requested police assistance; he appeared to be experiencing a mental health crisis with hallucinations…

emergency medicineforensic medicineproceduralcommunication
WAhospital2025-06-30

Inquest into the death of Houston PEEL

29y · Male·ligature compression of the neck (hanging)

…at 8:52 am and was later found hanging. Critical failures included: (1) incomplete collateral history from family; (2) no medical assessment during 4+ hour wait despite deteriorating mental state (confusion, wandering at…

emergency medicinepsychiatrycommunicationdelayolanzapine
WA2019-07-11

Inquest into the Death of Annabel NICOL

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

…ntal health care was of a high standard within resource constraints, but identified systemic failures: the Crisis Care Unit (CCU) was non-therapeutic and highly restrictive, limiting smoking and fresh air access which ex…

psychiatrycorrectional healthsystemdelaymirtazapine
WAcommunity2026-05-27

Inquest into the Death of David GRAY

58y · Male·Gunshot injury to the abdomen

…oroner made no adverse findings regarding police conduct but emphasized the importance of checking in with family and friends regarding mental health.

emergency medicineforensic medicine
VIChome2017-02-17

Finding into death of James Peter Berias

34y · Male·Stab wound to the chest

A 34-year-old man died from a stab wound to the chest inflicted by his intimate partner during a family violence incident. The death occurred in the context of a turbulent relationship characterised by mutual p…

general practicepsychiatrymethamphetamine
NSWcommunity2020-07-17

Inquest into the disappearance and suspected death of Max DAY

53y · Male·unknown - no postmortem examination possible

Max Day was reported missing on 20 January 2017, last confirmed alive on 25 January 2017. He had experienced a domestic violence incident on 6 January 2017, was detained under the Mental Health Act but assessed as not at…

psychiatryemergency medicine
NSWhome2017-03-30

Inquest into the death of John Inman BALE

60y · Male·single gunshot wound to the head, self-inflicted

A 60-year-old man with bipolar disorder, depression, and recent bereavement made a 000 call stating suicidal intent with a firearm. A PoliceLink telephonist (Mr Tant) engaged him for 17 minutes in skilled de facto negoti…

psychiatryemergency medicinecommunicationsystemolanzapine
NSWhospital2020-09-09

Inquest into the death of Grace HERINGTON

23y · Female·multiple blunt force injuries from fall from height

…ed her low risk. Key clinical lessons include: (1) the importance of obtaining collateral information from family members when assessing acute mental health presentations, as Grace minimised symptoms and family knew of b…

emergency medicinepsychiatrycommunicationsystemcannabis
QLDhome2012-09-13

CMC

36y · Female·Excited delirium

A 36-year-old woman died from excited delirium during a physical altercation with her 16-year-old son. She had longstanding alcohol and cannabis use, borderline personality disorder with features of post-traumatic stress…

psychiatryforensic medicinesystemdelayalcohol
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