Coronial

346 results for mental health distress

VICcommunity2014-01-30

Finding into death of Mihail Andrinopoulos

73y · Male·UNASCERTAINED

…certained; drowning could not be confirmed with certainty. Clinical lessons include: early engagement with mental health services for patients facing major life changes like dialysis initiation; thorough suicide risk ass…

general practicenephrology
WA2022-02-09

Inquest into the Suspected Death of Hok Cheun HOU

57y · Male·Unknown cause; likely drowning or injuries sustained when entering the water

Hok Cheun Hou, a 57-year-old Hong Kong national working as a general steward on the Coral Princess, disappeared in March 1989 approximately 200 nautical miles off Exmouth, Western Australia. He was last definitively seen…

VIChome2018-07-10

Finding into death of Carmelo Gusman

50y · Male·Single, contact-range shotgun discharge to the head

…in a murder-suicide. His death followed a workplace back injury that caused him significant psychological distress, loss of identity, and inability to work. He experienced depression, paranoia, and financial dependence o…

psychiatrypsychology
VIC2015-09-21

Finding into death of WJ

25y · Male·Pentobarbitone toxicity

…e coroner's detailed analysis found that pentobarbitone suicides in Victoria increasingly involve younger, mentally ill individuals rather than elderly people with terminal illness, with limited prevention opportunities …

pentobarbitone
NSWcommunity2021-10-22

Inquest into the death of Liselle HOUBERT

23y · Female·Multiple injuries received in a deliberate motor vehicle collision

…hicle collision caused by her partner Joshua Booth on 28 May 2020. Booth had been experiencing significant mental health issues including depression, PTSD, anxiety and panic disorder. He had been prescribed multiple anti…

psychiatrygeneral practiceantidepressant medications
NSWcommunity2022-10-07

Inquest into the death of Charli Powell

17y · Female·Hanging

…nd no evidence of strangulation. Systemic failures in domestic violence information sharing and inadequate mental health intervention during adolescence were highlighted as areas for improvement.

pathologypsychiatrysystemcommunicationcannabis
WAhome2013

Inquest into the Death of Hurley-Goodacre, Adam Michael

17y · Male·Ligature Compression of the Neck (Hanging) - Suicide

…. On the day of death, following parental discipline for punching a hole in his bedroom over relationship distress, Adam consumed alcohol and hanged himself impulsively in the garage. The coroner found the Department and…

paediatricspsychiatrysystemalcohol
WAhospital2017-07-11

Inquest into the Death of Beasley (also known as Graeme Leslie Syme)

49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …

…radoxical harm when notification requirements conflict with risk management; in modern practice, escalated mental health assessment and immediate crisis intervention protocols following notification of adverse legal outc…

emergency medicinetrauma surgerysystemdelaymethamphetamine
WAprison2022-07-22

Inquest into the Death of Callum MITCHELL

26y · Male·ligature compression of the neck (hanging)

…essment when requested in April 2019, instead offering a 2017 plan; (3) the barrier created when access to mental health care is contingent on a major mental illness diagnosis—Callum's personality disorder and functional…

psychiatrycorrectional healthsystemcommunicationtramadol
WAhospital2013

Inquest into the Death of Poole, Raymond Thomas

48y · Male·Gunshot wound to the head

A 48-year-old man died from a gunshot wound to the head during a police siege after having barricaded himself in a property. He had confronted the property owner with a sawn-off rifle, claimed to have wired explosives, b…

communicationsystemamphetamine
NSW2023-03-23

Inquest into the death of KT

27y · Male·Mixed drug (methylamphetamine and clozapine) toxicity

…nial of funeral leave, no consideration was given to offering KT support through cellmate placement. While mental health treatment was generally adequate within custodial constraints, system failures around pathology fol…

psychiatrytoxicologycommunicationsystemclozapine
VICcommunity2026-02-19

Finding into death of Kathleen Smith

53y · Female·Unascertained (presumed drowned)

…onal limitations as suicide risk factors; ensuring anxious patients with medical conditions receive timely mental health intervention; following up on psychiatric referrals; and escalating concern when patients express s…

general practiceorthopaedic surgerycommunicationdelaysertraline
VIChome2023-08-14

Finding into death of Anuruddha Bandara Abeysinghe

51y · Male·asphyxiation due to diffusion of exhaust fumes into a car

…nt to colleagues on multiple occasions. Despite union intervention urging reconsideration and highlighting mental health concerns, he was terminated on 27 July 2020. He died by exhaust asphyxiation the following morning.…

communicationsystemalcohol
VIChospital2016-10-25

Finding into death of Gladys Yvonne Melhuish

69y · Female·Complications of a probable bowel malignancy

…l lymphadenopathy and bowel thickening were identified; colonoscopy was not pursued due to concerns about distress and medication destabilisation. In March 2015, abdominal imaging revealed a caecal/ascending colon mass s…

oncologypalliative caremorphine
VIChospital2018-06-22

Finding into death of Liaqat Ali Hamid Kayani

44y · Male·Hypoxic brain injury secondary to heroin and alcohol toxicity

A 44-year-old male died from hypoxic brain injury caused by heroin and alcohol toxicity following an overdose. He had a history of depression, financial difficulties, and prior heroin use. After collapsing at a friend's …

emergency medicineintensive careheroin
WAprison2025-01-03

Inquest into the Death of Christopher John HILLSTEAD

59y · Male·ligature compression of the neck (hanging)

Christopher Hillstead, a 59-year-old prisoner serving a life sentence for wilful murder, died by suicide by hanging on 18 January 2021 at Acacia Prison, Western Australia. He had been pursuing tertiary education (master'…

psychiatrycorrectional healthcommunicationsystem
NSWcommunity2024-11-26

Inquest into the death of Andrew Chee Quee

51y · Male·gunshot wound to the chest

…justified use of force. Key clinical lesson: this case highlights the challenges police face responding to mental health crises, particularly when individuals are at immediate imminent risk and have acute suicidality wit…

psychiatrypsychologyalcohol
SAhospital2001-10-19

Coroner's Finding: McCARTHY Nancy Clare

67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…

…ed to vertebral compression fracture. She deteriorated acutely with confusion, agitation, and respiratory distress, necessitating Mental Health Act detention. CT imaging revealed advanced disseminated lung cancer with me…

general practiceemergency medicinediagnostic
VICmental health2021-01-22

Finding into death of Mr LY

42y · Male·Multiple injuries sustained in a fall from a height

Mr LY, a 42-year-old compulsory inpatient with extensive mental health history, died by suicide when he jumped from the Belford Road overpass during approved unescorted l…

psychiatry
WAhome2024-09-11

Inquest into the Death of Stephen Kenneth SHERWOOD

31y · Male·ligature compression of the neck (hanging)

Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted sui…

psychiatryemergency medicinecommunicationmethamphetamine
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