Coronial

402 results for suicide risk high

VICcommunity2014-06-30

Finding into death of Lewis John Muratori

50y · Male·Multiple injuries as a result of being struck by a train

A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he atten…

psychiatryemergency medicinecommunicationsystemaurorix
VIC2013-11-25

Finding into death of Rahul Prasad

28y · Male·Global cerebral ischaemic injury due to hanging

Rahul Prasad, a remanded prisoner with a serious psychotic condition and documented suicide risk, was discharged from the Acute Assessment Unit on 7 May 2010 with an S3 (potential) risk rating afte…

psychiatryintensive carediagnosticcommunication
SAhospital2013-04-24

Coroner's Finding: HOLLONDS Andrew David

37y · Male·compression of the neck consistent with hanging

…-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened hanging to his father. Although…

psychiatryemergency medicinesystemcommunicationtemazepam
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

… police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide risk during investigation, the officers did not provide required support materials, failed to document ri…

general practicepsychiatrycommunicationsystemfluoxetine
VIChospital2013-04-22

Finding into death of Evelyn Wright

62y · Female·Hypoxic brain injury complicating mixed drug toxicity

…of prescription medications on 5 September in the context of severe marital breakdown and a prior serious suicide attempt in July. The coroner found her suicide risk was assessed as moderate and she was discharged with …

emergency medicinepsychiatrydiagnosticcommunicationdiazepam
VIChome2014-12-18

Finding into death of Nathan James McRorie

20y · Male·Gunshot wound to the head

…ne. While homicide remained a possibility, it could not be proven on the balance of probabilities. The case highlights risks of substance abuse combined with firearm access and the challenges of investigating deaths in h…

methamphetamine
WAcommunity2018-07-12

Inquest into the Death of Shane Christopher FLANDERS

29y · Male·unknown, probably immersion

…year-old man with a complex psychiatric history including personality disorder, substance abuse, previous suicide attempt, and drug-induced psychosis, disappeared on 28 January 2016 after being released from custody. Hi…

psychiatryemergency medicinediagnosticcommunicationdextroamphetamine
SA2018-06-28

Coroner's Finding: CLAVELL Rodney Ian

46y · Male·Shotgun wound to the head (self-inflicted)

…gun wound to the head during a police siege at Marilyn's premises in Adelaide on 5 June 2014. Clavell was a high-risk wanted offender with extensive criminal history, substance abuse (methamphetamine, cocaine, steroids),…

communicationmethamphetamine
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

…tance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicidal ideation and assessed as very high risk. On 5 Ja…

psychiatryemergency medicinecommunicationsystemquetiapine
SA2009-05-19

Coroner's Finding: O'KEEFFE Daniel William Barry

34y · Male·hypoxic encephalopathy following hanging

… twice in custody after his bail was revoked for breaching conditions. Although appropriately identified as high-risk and placed on a yellow sheet supervision protocol, he was able to seclude himself in his cell during a…

psychiatryintensive caresystemcommunicationcitalopram
VIChome2025-01-09

Finding into death of C M

25y · Female·Neck compression secondary to hanging

CM, a 25-year-old woman experiencing depression, anxiety, and substance misuse, died by suicide while in an intimate partner relationship characterised by documented family violence. She presented to h…

emergency medicinepsychiatrydiagnosticsystemalprazolam
VICmental health2011-10-14

Finding into death of Amanda Billie Jo Kennedy

26y · Female·compression of the neck consequent upon hanging

Amanda Kennedy, a 26-year-old woman with a history of trauma, substance abuse, depression, and multiple suicide attempts, died by hanging in the Northern Psychiatry Unit on 24 June 2010 while under involuntary psychia…

psychiatryemergency medicinecommunicationsystemquetiapine
VICmental health2020-12-18

Finding into death of Michelle Williams

46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia

… observation at 12.00pm when two LDU nurses were assisting in the HDU; failure to perform a required formal risk assessment despite observable deterioration in her mental state that morning; and inadequate environmental …

psychiatryintensive caresystemdiagnosticolanzapine
QLDhome2016-08-26

Winbank, Leslie Geoffrey

53y · Male·Self-inflicted gunshot wound to the head

… at 7:13pm. The coroner found police actions appropriate and timely. Clinical lessons include recognising suicide risk in patients with multiple stressors (chronic pain, relationship breakdown, depression history), ensu…

psychiatrypain medicineoxycodone
QLD2014-09-16

Hurst, Charles Kingston

38y · Male·Hanging

…ough Correctional Centre in November 2012. He had been assessed using the Queensland Corrective Services At-Risk Management procedure and was classified as low risk on 5 November 2012, two days before his death. While th…

psychiatrycorrectional healthsystemmirtazapine
NSW2024-12-12

Inquest into the death of Mr S

57y · Male·Hanging

…ion with psychotic features and was recommended by a psychiatrist for placement in a two-occupant cell as suicide risk mitigation, he was placed alone due to administrative miscommunication. A reception officer misinter…

psychiatrycorrectional healthcommunicationsystemfluoxetine
WAmental health2024-08-28

Inquest into the Death of Peter Jonathon Rex BOLTON

36y · Male·ligature compression of the neck (hanging)

… a locked mental health ward. He was on hourly observations and had recently denied suicidal ideation, with risk assessments rating him at low self-harm risk. Between observations at 2pm and 3pm, he created a ligature fr…

psychiatryemergency medicinehaloperidol
VIChome2022-08-31

Finding into death of B L

28y · Male·neck compression consequent upon hanging

…nt suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide threats and high-lethality attempts, then discharged on 27 February with brief ACIS follow-up. Key clinic…

psychiatryemergency medicinecommunicationsystemsodium valproate
VIC2025-11-12

Finding into death of Wendy Ann McCabe

40y · Female·hypoxic ischaemic encephalopathy due to ligature compression of the neck

…burglary, she was held at Knox Police Station on 2 December 2021. Police delayed completion of her Detainee Risk Assessment (DRA) despite her having a 'S4' suicide risk rating on the system. She was issued a standard bla…

correctional healthemergency medicineproceduralcommunicationmethadone
TAScommunity2020-07-17

Coroner's Finding: Lyons, Matthew Clayton

47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)

…d deceased near the hospital on 23 October. The coroner could not definitively determine whether this was suicide or accidental overdose, but clinical lessons include: urgency in securing mental health respite for patie…

psychiatrygeneral practicecommunicationsystemquetiapine
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