Coronial

191 results for major_depressive_disorder

TAShome2018-02-28

Coroner's Finding: Evans, Jillian and John

62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs …

In September 2013, Mr John Evans (62) killed his wife Jillian after he experienced psychosis manifesting as delusions about chemical infestation of their home. The coroner found Mr Evans was psychotic at the time of deat…

psychiatrygeneral practicediagnosticcommunicationrisperidone
VICmental health2016-12-08

Finding into death of Joseph Pezzimenti

60y · Male·Global cerebral ischaemia post cardiac arrest in the setting of neck compression

Joseph Pezzimenti, a 60-year-old involuntary psychiatric patient, died from cerebral ischaemia following hanging by a tracksuit cord in a Low Dependency Unit bathroom. Key clinical lessons include: communication difficul…

psychiatryintensive carediagnosticcommunication
SA2004-08-06

Coroner's Finding: TURNER Troy Phillip

36y · Male·hanging

Troy Phillip Turner, aged 36, died by hanging in his prison cell on 2 September 2001 while on remand for serious domestic violence-related offences. The coroner identified several preventable failures: (1) Duty Superviso…

psychiatryemergency medicineproceduralsystemfluvoxamine
VIChospital2011-05-04

Finding into death of Ms P

30y · Female·Multi organ failure from hydrochloric acid ingestion

Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 …

psychiatrygeneral practicecommunicationsystemtemazepam
VIC2010-02-12

Finding into death of Wesley Robert Jennings

42y · Male·incised wound to the neck

Wesley Robert Jennings, a 42-year-old male with long-standing depression, anxiety, hepatitis C and substance use history, died by suicide by incised neck wound whilst on remand in prison. The coroner found no demonstrabl…

psychiatrypsychologycommunicationsystemcitalopram
TAShome2024-04-30

Coroner's Finding: Mason, Geoffrey

38y · Male·gunshot wound to the left side of the neck resulting in basal skull fracture, su…

Geoffrey Russell Mason, aged 38, died from a gunshot wound to the neck fired by Constable Mitchell during a police response to a domestic incident on 17 February 2020 in Tasmania. Mason was intoxicated, had a long histor…

general practiceemergency medicinesystemalcohol
QLDmental health2013-07-02

Mrs B

52y · Female·Hanging due to depression

Mrs B, a 52-year-old woman with a 17-year history of recurrent depression, suicidal ideation, and borderline personality traits, was admitted to Cairns Base Hospital Mental Health Unit on 11 March 2008 with escalating su…

psychiatrycommunicationsystemdiazepam
QLDmental health2015-06-10

McDonnell, Kevin Joseph John

80y · Male·Drowning

An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…

psychiatryemergency medicinedocumentationcommunicationolanzapine
VICmental health2017-02-07

Finding into death of Esther Ng Kit Ching

53y · Female·Hypoxic brain injury due to hanging

A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her deat…

psychiatrycommunicationdelaymirtazapine
VICmental health2012-04-30

Finding into death of Travis Andrew McNees

18y · Male·Multiple injuries due to impact by train

Travis McNees, 18-year-old male, died by suicide on 4 October 2010 after absconding from Upton House psychiatric unit. He presented to ED on 29 September with paracetamol/panadeine overdose following relationship breakdo…

psychiatryemergency medicinecommunicationsystemparacetamol
SAcommunity2004-07-16

Coroner's Finding: DINSDALE Cheree Ann and KLINGNER Peter James

20y · Unknown·Traumatic brain damage complicating gunshot wound to the head

Two young adults aged 20 died from gunshot wounds to the head on 29-30 May 2001 in what appears to be a murder-suicide involving Peter Klingner and his girlfriend Cheree Dinsdale. Klingner had paranoid schizophrenia with…

psychiatryemergency medicinediagnosticcommunicationolanzapine
WA2013-05-30

Inquest into the Death of Mcdonald, Charles Edward

38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia

A 38-year-old remand prisoner with schizophrenia on clozapine died suddenly in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to prison on 20 Jul…

psychiatrypharmacologycommunicationsystemclozapine
VICmental health2022

Finding into death of LKV LKV

73y · Male·Neck compression in the circumstances of hanging

A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…

psychiatrygeneral practicediagnosticsystemescitalopram
NSWmental health2017-06-09

Inquest into the death of Ahlia RAFTERY

18y · Female·neck compression due to hanging

An 18-year-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate communication of previous s…

psychiatrydiagnosticcommunicationfluoxetine
VIChome2014-12-10

Finding into death of Phoebe Handsjuk

24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…

Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment building on 2 December 2010. The coroner found she entered a garbage c…

psychiatrypsychologycommunicationsystemzolpidem
NSWhome2017-10-13

Inquest into the death of D T

13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…

A 13-year-old boy with depression, migraine, school refusal and family instability died by intentional self-inflicted means. His general practitioner provided inadequate mental health assessment, initiated antidepressant…

general practicepsychiatrydiagnosticcommunicationfluoxetine
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide on 2 October 2007 after stepping into the path of a truck. She had …

psychiatrygeneral practicecommunicationsystemstillnox
NSWmental health2025-03-31

Inquest into the Death of G.P.

41y · Male·Multiple traumatic injuries

This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…

psychiatryemergency medicinediagnosticcommunicationlisdexamfetamine
NSWmental health2018-12-19

Inquest into the death of R R

38y · Female·neck compression (hanging)

RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to Bloomfield Hospital on 12 April 2015 following an overdose with stated…

psychiatryemergency medicinecommunicationsystem
NSWmental health2024-03-06

Inquest into the death of RA

64y · Female·hypoxic ischemic encephalopathy caused by neck compression and hanging

A 64-year-old woman with a history of childhood trauma, anxiety and depression was admitted to an acute mental health unit (Kurrajong Unit) under involuntary care following a suicide attempt. Within 24 hours, she accesse…

psychiatryemergency medicinesystemproceduralmirtazapine

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