Coronial

366 results for psychiatric admission assessment

NSWhospital2014-08-22

Inquest into the death of Alana GOLDSMITH

21y · Female·Multiple injuries sustained from being struck by a train; death by suicide while…

…oroner identified multiple failings in her care: the admitting nurse failed to complete the suicide risk assessment document, prior discharge summaries were not obtained (which documented a previous suicide attempt and h…

psychiatrygeneral practicecommunicationsystemolanzapine
NSWcommunity2025-08-22

Inquest into the disappearance and suspected death of Habtom Ghilagaber

30y · Male·unknown - no postmortem examination performed

…absence of remains or postmortem examination. Critical clinical lessons include the importance of early psychiatric follow-up and involuntary detention protocols—Habtom had been hospitalised with schizophreniform psycho…

psychiatrypsychologysystemcommunicationantipsychotic medication
VICcommunity2015-10-06

Finding into death of Gregory Anderson

54y · Male·gunshot wound to the chest

Gregory Anderson died from a gunshot wound to the chest sustained during a police response at Bunguyan Reserve on 12 February 2014. He had fatally assaulted his 11-year-old son Luke during a cricket practice session with…

psychiatryforensic medicinediagnosticsystemdiazepam
WAcommunity2020-11-04

Inquest into the Death of Andrew John KEY

49y · Male·incised injury to the neck

…licting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health assessment and crisis response. On 5 August, psychiatric assessment in ED correctly followed the Mental Health Act …

psychiatryemergency medicinecommunicationsystemquetiapine
VICmental health2014-09-29

Finding into death of Kelvin Robert Davidson

75y · Male·Hanging

Kelvin Davidson, a 75-year-old man with complex psychiatric history including prior self-harm and attempted hanging, was admitted to Baringa Aged Psychiatric Unit …

psychiatrysystemcommunicationtemazepam
WAhospital2015-02-26

Inquest into the Death of John Vincent KEARNEY

49y · Male·Carbon monoxide toxicity

…d to Sir Charles Gairdner Hospital ED on 26 March 2010 with suicidal ideation triggered by work stress. Psychiatric clinicians conducted comprehensive assessment, overnight observation, and reassessment. Though his wife…

psychiatryemergency medicineantidepressant
WAhospital2009-08-13

Inquest into the Death of Greeuw

45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction

…romazine, olanzapine, benztropine, lamotrigine), no physical examination was performed during her 11-day admission and no bowel chart was implemented. Critical gaps in care included: confusion between the general practi…

psychiatrygeneral practicediagnosticcommunicationchlorpromazine
VIChospital2015-05-28

Finding into death of Naomi Charmaine Mahon

33y · Female·multiple injuries sustained when struck by a train

… had been brought to the ED by police under Mental Health Act section 10 after threatening suicide. The psychiatric team assessed her as not meeting involuntary treatment criteria and admitted her voluntarily to the psy…

psychiatryemergency medicinerisperidone
TAShome2019-10-16

Coroner's Finding: Powell, Stephen Maxwell

72y · Male·exsanguination (blood loss) from severed femoral artery

…phrenia, died by exsanguination from a self-inflicted femoral artery laceration. He was discharged from psychiatric inpatient care on a community treatment order on 14 December 2017 and died on 26-27 December 2017. The …

psychiatrygeneral practicehaloperidol decanoate
SAhospital2005-04-05

Coroner's Finding: HOLLENS Christopher

44y · Male·aspiration pneumonia

…, traumatic brain injury, spastic paraparesis, and epilepsy, died of aspiration pneumonia after a 15-day admission to Royal Adelaide Hospital. He was transferred from Glenside psychiatric hospital on 11 November 2002 wi…

psychiatrygeneral medicinephenytoin
TASmental health2016-01-29

Coroner's Finding: Mr D

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

…y of mental illness and suicide. After a previous suicide attempt by asphyxiation, he was admitted to a psychiatric inpatient unit for assessment and treated with antidepressants and anxiolytics. He was discharged after…

psychiatrygeneral practicecommunicationsystemescitalopram
VICcommunity2017-08-25

Finding into death of Thomas Edward Mackenzie Hall

41y · Male·Injuries sustained in a motor vehicle incident (driver) in a man with coronary a…

…is mother's car unlicensed and at excessive speed into oncoming traffic. He had a documented history of psychiatric illness with multiple involuntary admissions, medication non-compliance, and recent suicidal ideation e…

psychiatryemergency medicinecommunicationsystemrisperidone
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

…eneral care was reasonable but identified significant deficiencies in discharge planning: PARC step-down admission was inappropriately unavailable due to accommodation funding restrictions; ACIS referral was not arrange…

psychiatryemergency medicinesystemdelaymirtazapine
VICmental health2017-11-14

Finding into death of Sandra Michelle Liddy

44y · Female·Heroin toxicity

…iddy, aged 44, died from heroin toxicity while on unescorted day leave from an involuntary mental health admission. She had a 25-year psychiatric history with paranoid schizophrenia and polysubstance use disorder but ha…

psychiatryemergency medicineheroin
SAhospital2020-07-02

Coroner's Finding: WHATLEY Deborah Rose

55y · Female·ischaemic heart disease complicated by epilepsy, asthma and schizophrenia

…zophrenia, epilepsy, asthma and COPD presented to hospital with abdominal pain and confusion. Initial ED assessment treated presumed UTI and discharged her. She returned the next day with worsening psychotic symptoms and…

emergency medicinepsychiatryclozapine
VICmental health2012-01-31

Finding into death of John Bernard Tuffy

48y · Male·drowning

…s to separate transferring patients. The death highlights gaps in observation protocols for disoriented psychiatric patients awaiting transfer.

psychiatryemergency medicinecommunicationsystemtemazepam
WAcommunity

Inquest into the Death of Gary John LYDDIETH

54y · Male·Unknown - death established on balance of probabilities but manner and cause und…

…year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prior su…

psychiatrygeneral medicinesystemcommunication
WAcommunity2017-09-06

Inquest into the Death of James Michael Chee Ming YUNG

42y · Male·Multiple injuries sustained in motor vehicle crash

…015, despite signs of relapse and non-compliance, the treating team opted for outpatient management over admission due to bed unavailability and the patient's extreme fear of hospitalisation. The patient absconded to Me…

psychiatryemergency medicinedelaysystempaliperidone depot
VICcommunity2013-01-31

Finding into death of Stuart Beverley

31y · Male·Hanging

…disorder presented to mental health services after a suicide attempt on 30 March 2005, discharged after psychiatric assessment at Maroondah Hospital ED. Following several crisis presentations over the next week, he was …

psychiatryemergency medicinecommunicationdelaydiazepam
VICcommunity2014-08-13

Finding into death of Frederick Russell Morgan

48y · Male·Unknown causes (presumed suicide by drowning)

…1 from Mt Martha beach. He had experienced severe depression triggered by business financial crises, tax assessment concerns, and his father's death. Despite seeing his psychotherapist Dr R. on 15 July 1971—when Mr Morga…

psychiatrypsychologydiagnosticdelayantidepressant medication
178919

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