Coronial

191 results for major_depressive_disorder

SAhome2004-01-29

Coroner's Finding: ARANY Eva and Jeno

Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…

An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identifying he owned seven firearms and pos…

psychiatrygeriatric medicinecommunicationsystemparoxetine
SAhome2023-12-06

Coroner's Finding: Cullen, Jason Mark

37y · Male·mixed drug toxicity with fentanyl as the principal agent

37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…

neurosurgerypsychiatrycommunicationsystemfentanyl
VIChome2014-05-15

Finding into death of Georgia Susan Cheal

31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…

Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…

general practicepsychiatrycommunicationsystemoxycodone
ACThospital2014-06-02

Findings Into The Death Of Mijo Galinec

69y · Male·asphyxia by hanging

A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…

psychiatryemergency medicinecommunicationsystemolanzapine
NSW2023-11-16

Inquest into the death of DP

52y · Male·hanging

A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…

psychiatrygeneral practicediagnosticsystemduloxetine
NSWcommunity2011-07-22

01ab 092558 redacted

15y · Male·multiple blunt force injuries as a result of being hit by a train

AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…

general practicepsychiatrymedicationcommunicationescitalopram
VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

31y · Female·neck compression in the circumstances of hanging

Tessa Ballam, a 31-year-old accountant with longstanding depression, anxiety, bulimia nervosa, and borderline personality disorder (BPD), died by hanging in August 2015. She had experienced workplace difficulties with he…

psychiatrypsychologycommunicationsystemalcohol
VIChospital2014-09-12

Finding into death of Nola Margaret Moxon

77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression

77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …

psychiatrygeriatric medicinecommunicationsystemvenlafaxine
NSWhome2022-05-27

Inquest into the death of WX

54y · Male·gunshot wound to the head

WX, a 54-year-old with longstanding depression, substance abuse (opioids, benzodiazepines), and a 2008 suicide attempt, died by gunshot wound on 27 April 2015. Despite this psychiatric and substance abuse history, he hel…

psychiatrypsychologysystemcommunicationcodeine
VIChome2025-09-11

Finding into death of ZSQ

26y · Female·Multiple stab wounds

ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…

emergency medicinepsychiatrycommunicationsystemcocaine
VIChome2020-11-16

Finding into death of Hilton Davis

50y · Male·mixed drug (oxycodone and methadone) and ethanol toxicity

A 50-year-old Torres Strait Islander man died from mixed drug (oxycodone and methadone) and ethanol toxicity in the context of family violence and suicidality. He had a 7-year history of suicide attempts and mental healt…

general practiceforensic medicinecommunicationsystemoxycodone
QLDcommunity2012-07-05

Patient A

49y · Male·Hanging

A 49-year-old man with bipolar affective disorder and recurrent depression experienced a relapse while in Tasmania and was referred to a community-based Acute Care Team in Queensland in November 2009. Despite his partner…

psychiatrygeneral practicediagnosticcommunicationsertraline
QLD2018-06-28

Hamilton, Blair Andrew

54y · Male·Extensive burns due to detonation of LPG gas cylinder

A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…

psychiatrygeneral practiceproceduralcommunicationvenlafaxine
SAcommunity2003-05-27

Coroner's Finding: GILLIES Wayne John

45y · Male·Bullet wound to the head - self-inflicted

A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…

psychiatrygeneral practicecommunicationsystemvenlafaxine
VIC2024

Finding into death of W B

59y · Male·Gunshot wound of head

A 59-year-old police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP ma…

general practicepsychiatrycommunicationsystemdiazepam
QLDhospital2017-09-07

Mr R - Non-inquest findings

63y · Male·Multiple injuries due to fall from height

A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…

neurosurgeryneurologysystemcommunicationcitalopram
VIChome2021-09-08

Finding into death of DA

38y · Male·Mixed drug toxicity

DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…

general practicepsychiatrycommunicationsystemcodeine
VIChome2014-06-27

Finding into death of Caroline Courtenay Webster

53y · Female·Combined drug toxicity (propranolol and insulin)

A 53-year-old registered nurse with longstanding depression, anxiety and benzodiazepine dependency died from combined drug toxicity (propranolol and insulin) in what was determined to be an intentional overdose. Ms Webst…

psychiatrygeneral practicesystemcommunicationpropranolol
NSWmental health2019-12-04

Inquest into the death of Mitchell FLOOD-SMITH

23y · Male·Multiple injuries sustained following collision with a train

A 23-year-old man with a history of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2…

psychiatryparamedicinecommunicationsystemrisperidone
WA2017-03-07

Inquest into the Death of Barry Matt STUART

49y · Male·ligature compression of the neck (hanging)

Barry Matt Stuart, a 49-year-old prisoner at Hakea Prison, died by suicide via ligature compression of the neck in November 2013. Critical clinical lessons include: (1) maintaining psychiatric continuity of care is essen…

psychiatrygeneral practicemedicationsystemolanzapine
167810

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.