Coronial

475 results for psychiatric admission

VICmental health2015-07-03

Finding into death of Anthony Travaglini

40y · Male·combined drug toxicity in a man with asthma (undiagnosed) and sleep apnoea

…oaffective disorder, severe sleep apnoea, and undiagnosed asthma, died from combined drug toxicity on a psychiatric high-dependency unit. Critically, his earlier clinical records documenting sleep apnoea were not availa…

psychiatryrespiratory medicinesystemcommunicationzuclopenthixol
NSWcommunity2015-01-23

Inquest into the death of XY

17y · Female·multiple blunt force injuries after being struck by a train

17-year-old X died by suicide on 18 December 2012 after being struck by a train. She received multiple psychiatric admissions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, …

psychiatryemergency medicinefluoxetine
VIChospital2012-12-13

Finding into death of William Andrew Poskitt

31y · Male·Injuries sustained in a fall from height

… with recently diagnosed HIV and Pneumocystis carinii pneumonia, died by suicide during a 4-day hospital admission. Despite requesting psychiatric assessment three times and displaying clear signs of psychological distr…

infectious diseasespsychiatrycommunicationdiagnostictrimethoprim
VIChome2024-10-09

Finding into death of D M

43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…

A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality di…

psychiatrygeneral practicecommunicationsystemtapentadol
VICmental health2017-05-18

Finding into death of Derek Hamilton

46y · Male·Cerebral ischaemia secondary to compression of the neck in circumstances of hang…

Derek Hamilton, a 46-year-old involuntary psychiatric patient with cluster B personality disorder and recurrent depression, died from cerebral ischaemia seco…

psychiatryintensive caresystemcommunicationmirtazapine
WAcommunity2018-07-12

Inquest into the Death of Shane Christopher FLANDERS

29y · Male·unknown, probably immersion

Shane Flanders, a 29-year-old man with a complex psychiatric history including personality disorder, substance abuse, previous suicide attempt, and drug-induced psy…

psychiatryemergency medicinediagnosticcommunicationdextroamphetamine
SA2008-06-06

Coroner's Finding: FORSAITH Renald Lance

51y · Male·neck compression due to hanging

A 51-year-old man on remand in prison died by hanging in his cell. He had a psychiatric history including depression and a family history of suicide, but showed no signs of self-harm risk dur…

psychiatrycorrectional healthsystem
VICmental health2026-04-27

Finding into death of GM

Female·Fulminant hepatic failure due to paracetamol toxicity

…anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She reported ongoing suicidal thoughts but engaged well in safety plann…

psychiatryintensive careparacetamol
WAmental health2015-12-31

Inquest into the Death of Carly Jean ELLIOTT

Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…

Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…

psychiatryemergency medicinecommunicationsystemantidepressants
TAShospital2022-07-01

Coroner's Finding: CL de-identified

33y · Female·hanging

…ning attempt. The coroner found that discharge was inappropriate and would likely have been prevented by admission. The psychiatric medical officer failed to adequately consider the patient's longitudinal history of dep…

psychiatryemergency medicinediagnosticcommunicationsertraline
NSWhospitalNew2026-06-19

Inquest into the Death of Simon Myles Mackay

37y · Male·Neck compression and the complications thereof

Simon Mackay, age 37, was admitted as an involuntary psychiatric patient on 12 July 2022 for acute methamphetamine-induced psychosis with paranoia and aggression, compl…

psychiatryaddiction medicinepaliperidone
WAhospital2023-05-26

Inquest into the Death of Jacob George Isaac TAULELEI

28y · Male·Multiple injuries sustained when struck by a freight train

…sing intent to jump in front of a train. Despite being assessed as moderate risk and deemed suitable for admission, he was discharged due to lack of available beds. He re-presented on 7 February 2020 with ongoing severe…

psychiatryemergency medicinediagnosticcommunicationduloxetine
WAhospital2024-05-06

Inquest into the Death of Devan Beau GINBEY

20y · Male·Hypoxic brain injury following ligature compression of the neck (hanging)

…with self-harm and active suicidal ideation with a stated plan. Despite appropriate initial medical and psychiatric assessment, he was placed in a noisy, inappropriate ED overflow area while awaiting a voluntary mental …

emergency medicinepsychiatrysystemdelay
VIChospital2025-10-13

Finding into death of David Greville Edward Horne

47y · Male·Unascertained; most likely cardiac arrhythmia possibly triggered by obstructive …

…sorder, and severe obstructive sleep apnoea, died suddenly at Maroondah Hospital while under compulsory psychiatric treatment. He experienced two episodes of respiratory distress on 5 and 8 December 2023, likely exacerb…

psychiatryrespiratory medicinediazepam
NSWhome2010-12-13

Coroner's Finding: Paul Justyn Brauer

64y · Male·Large pulmonary embolus (origin undetermined)

Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. Th…

psychiatrygeneral medicinediagnosticmedicationlactulose
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

…ir relationship. His presentation to Monash on 9 November 2010 with suicidal ideation was assessed by a psychiatric nurse (Nurse Sebille) rather than a child and adolescent psychiatrist as requested by his GP. The asses…

psychiatrygeneral practicediagnosticcommunicationtemazepam
SA2003-12-18

Coroner's Finding: LINDSAY Margaret

38y · Female·neck compression due to hanging

…ging in Adelaide Women's Prison on 23 May 2001 whilst remanded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite comprehensive documentation fro…

psychiatrycorrectional healthcommunicationsystemdiazepam
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

26y · Male·Not able to be determined - skeletalised remains

… use and a period of erratic behaviour. He was briefly assessed by nursing staff but discharged without psychiatric review. Community mental health follow-up was arranged but failed due to inability to contact him (no p…

emergency medicinepsychiatrycommunicationsystemolanzapine
SAhospital2011-12-22

Coroner's Finding: SWAVLEY Matthew Tyson

39y · Male·cardiomegaly

…lawful and appropriate, and that his sudden collapse could not have been foreseen. Medical assessment on admission included ECG showing sinus tachycardia attributed to dehydration, chest X-ray, and bloods. Close observa…

psychiatryemergency medicineolanzapine
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 …

…is was very difficult; key learning points include importance of collateral history from family, timely psychiatric consultation, adequate dosing of antipsychotics when psychosis is diagnosed, and proper documentation o…

psychiatrygeneral practicediagnosticcommunicationrisperidone
178924

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