Coronial

390 results for mental health deterioration

VIChospital2012-06-04

Finding into death of Michael Cleary

79y · Male·Septicaemia — Septic Arthritis Right Knee

…ollowing a fall from a truck on 18 March 2011. He initially declined medical treatment despite significant health deterioration. After a Mental Health Act assessment on 23 March 2011, he was admitted to care and transpor…

intensive careemergency medicine
SAhospital2021-11-25

Coroner's Finding: Ansink, Matthew Wade

32y · Male·Subarachnoid haemorrhage due to rupture of basilar artery aneurysm

…tery aneurysm. He was found collapsed in the shower while an inpatient on an Inpatient Treatment Order for mental health reasons. He had recently been admitted following suicidal ideation and tested positive for methamph…

psychiatryemergency medicinealprazolam
VICmental health2009-12-01

Finding into death of Francis John Willcox

81y · Male·myelodysplasia in an elderly man with dementia

…e of appropriate palliative care planning, and ensuring adequate nutritional support and monitoring during mental health admissions. Early involvement of geriatric and palliative care specialists, and consideration of un…

psychiatrygeriatric medicine
TAScommunity2021-04-20

Coroner's Finding: Young, Jeremy Dean

45y · Male·drowning and intoxication with methamphetamine and other substances

…d for comprehensive substance use disorder management, recognition of drug-induced psychosis and paranoia, mental health crisis assessment in heavily intoxicated patients, and documentation of unexplained wounds. No prev…

pathologyaddiction medicinemethamphetamine
SAhospital2020-05-08

Coroner's Finding: FORT Merilyn Jane

62y · Female·general inanition on a background of end-stage dementia

…aged 62, died from general inanition on a background of end-stage Alzheimer's dementia whilst subject to a Mental Health Act Inpatient Treatment Order. She presented with severe behavioural disturbance, agitation, and re…

geriatric medicinepsychiatryclonazepam
SAmental health2002-02-05

Coroner's Finding: COCCA Angelo

63y · Male·respiratory arrest caused by bronchopneumonia secondary to swallowing problems c…

…caused by bronchopneumonia secondary to swallowing problems from severe dementia. He was an inpatient in a mental health facility under a detention order. The coroner found no quality-of-care concerns and documented that…

psychiatrygeriatric medicine
VIChome2021-05-20

Finding into death of Brodie Moran

8y · Male·Suffocation

… Ms Finch, on 8 March 2018. Ms Finch had a history of depression and anxiety, experiencing significant deterioration in mental health following her grandmother's death in July 2017. In the weeks before the death, she di…

general practicepsychiatrysystemvenlafaxine
VICcommunityNew2026-05-29

Finding into death of EKU

53y · Female·Multiple injuries sustained in a fall from height

…pts to increase antipsychotic medication, she declined dose changes. On 16 May 2024, while under community mental health supervision, she fell from the third floor of Emporium Melbourne Shopping Centre (50-60 metres), su…

psychiatrypsychologybrexpiprazole
VICcommunity2020-02-28

Finding into death of Robb Thomas Lawson

48y · Male·unascertained

Robb Thomas Lawson, a 48-year-old man with a long history of mental illness including depression, anxiety, paranoia and multiple suicide attempts, disappeared in July 2007 af…

psychiatrycommunicationolanzapine
NSWhospital2020-09-17

Inquest into the death of Cemil GULER

80y · Male·metastatic hepatocellular carcinoma

…d man, died from metastatic hepatocellular carcinoma at Braeside Hospital. He was a forensic patient under Mental Health Act detention after being found not guilty by reason of mental illness of a murder charge. He was t…

oncologypalliative care
QLDcommunity2017-08-17

JJKD - Non-inquest findings

34y · Male·drowning

… drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and private services. Critical failures included: …

psychiatrycommunicationsystemclozapine
NSWcommunity2022-09-16

Inquest into the death of M G

51y · Male·multiple injuries sustained by a high velocity fall from a height

…experienced Sergeant McCarthy engaging him for over an hour using de-escalation techniques consistent with mental health crisis training. Despite McCarthy's attempt to physically intervene when he assessed imminent dange…

psychiatryemergency medicine
VIChome2012-02-14

Finding into death of Edo Travaglia

54y · Male·Carbon monoxide poisoning

…ent people with complex needs remain at high suicide risk despite external improvements; the importance of mental health monitoring in primary carers; and identifying warning signs in patients with depression, past suici…

psychiatrygeneral practicebenzodiazepines
VICmental health2021-08-20

Finding into death of Marilyn

62y · Female·Unascertained

…ed at Caulfield Hospital on 27 October 2019 with an unascertained cause. She was admitted via the ED under mental health legislation with deteriorating mental state and poor oral intake. During her 7-week acute aged psyc…

psychiatrygeriatric medicinefluoxetine
WAcommunity2020-02-03

Inquest into the Death of Jose DA SILVA

34y · Male·unascertained; most likely immersion after swimming at City Beach

…s apartment in an untidy state—uncharacteristic for him. While he had no documented suicidal ideation, his mental health appeared to be deteriorating. The coroner could not definitively determine whether his death was ac…

psychiatrygeneral practiceolanzapine
NSWmental health2020-02-07

Inquest into the death of Chella Leijten

57y · Female·metastatic lung carcinoma

…lted from natural disease progression. An inquest was mandatory as she died in lawful custody (involuntary mental health detention).

psychiatrypalliative care
VICcommunity2017-02-20

Finding into death of Finding Peter Graham Chaucer

48y · Male·Injuries sustained when struck by a train

A 48-year-old man with mental health issues including depression and possible bipolar disorder died by suicide following train strike. H…

psychiatryemergency medicinecommunicationsystemlithium
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

…ly in 2020 via DNA), and inadequate policy frameworks. The case demonstrates how poor coordination between mental health services, university pastoral care, social work, and law enforcement can allow vulnerable foreign s…

psychiatrypsychologysystemcommunicationantipsychotic medication
SAhospital2004-05-19

Coroner's Finding: WOZNIAKOWSKI Andrzej

83y · Male·inanition with lobar pneumonia

An 83-year-old man with organic brain syndrome and severe malnutrition was detained under the Mental Health Act after being found in severe self-neglect. He was admitted to hospital where he received compreh…

emergency medicinepsychiatry
TASmental health2016-01-29

Coroner's Finding: Mr D

57y · Male·Multiple fatal injuries following a fall from height onto rocks

…ed by suicide after falling from a cliff in northern Tasmania in July 2014. He had experienced progressive mental health deterioration over 12 months, including depression, anxiety, and suicidal ideation, triggered by fa…

psychiatrygeneral practicecommunicationsystemescitalopram
178920

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