Coronial

746 results for psychiatric treatment

VICcommunity2025-11-11

Finding into death of Veronica Norah Cheney

43y · Female·undetermined

Veronica Cheney disappeared on 1 March 1945 at age 43 from Melbourne. She had a significant psychiatric history including hospitalisation for psychosis and auditory hallucinations at Royal Park and Mont Park…

psychiatrypathology
VIC2010-01-11

Finding into death of Glenn Leslie Stevenson

45y · Male·Multiple injuries and fall from a height

…, died by suicide by jumping from the Westgate Bridge on 6 April 2008. He had been admitted to Sunshine Psychiatric Hospital the previous day after presenting to the Royal Melbourne Hospital ED intoxicated with suicidal…

psychiatryemergency medicinesystemalcohol
VICcommunity2018

Finding into death of Konstantinos Eleftheriou-Tragakis

36y · Male·Hanging

…h schizoaffective disorder, substance use disorder, and previous psychotic episodes was discharged from psychiatric inpatient care after being absent without leave for 72 hours. On 4 June 2017, he contacted the Crisis A…

psychiatrycommunicationsystemrisperidone
QLD2013-05-16

Lalara, Hazel Marie

44y · Female·Dilated cardiomyopathy

… neuropathy, was remanded in custody to The Park Centre for Mental Health in January 2009. She received psychiatric treatment for acute psychosis and appropriate general medical care for her comorbidities. On 29 January…

psychiatrygeneral practicerisperidone
VIC2020-10-29

Finding into death of Bo Zhao

31y · Male·Combined Drug Toxicity (amitriptyline and metoclopramide)

…ssments in 2017-2018 identified depression, anxiety, and despair but he did not engage with recommended psychiatric treatment or counselling. He had cancelled a scheduled psychological consultation on the day of his dea…

psychiatrygeneral practicedelayamitriptyline
TAScommunity2020-08-13

Coroner's Finding: Wright, Maria Rebekah

31y · Female·drowning, deliberately self-inflicted with intention of ending life

…hich she required mechanical restraints and life-saving N-acetylcysteine infusion. The coroner found her treatment at RHH was appropriate and likely life-saving, with excellent nursing care and proper documentation of r…

psychiatrypsychologyparacetamol
TAShome2015-10-02

Coroner's Finding: Ms G de-identified

Female·hanging (suicide)

…icide in November 2014. She had been admitted to hospital six times for detoxification and mental health treatment between 2009 and 2013, but remained non-compliant with follow-up care and repeatedly relapsed into alcoh…

psychiatryaddiction medicinesystemalcohol
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
TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

… with hammer) and was assessed by CATT. Critically, the registered nurse did not conduct a face-to-face psychiatric assessment—the consultant psychiatrist made discharge decisions based only on phone discussion without …

psychiatryemergency medicinediagnosticcommunicationquetiapine
ACTaged care2026-06-11

Inquest into the death of Peter Wallace

76y · Male·congestive cardiac failure complicated by type 2 respiratory failure

Peter Vernon Wallace was a 76-year-old man with schizophrenia subject to a Psychiatric Treatment Order, living in aged care. He had serious physical comorbidities including congestive cardia…

psychiatrygeriatric medicinezuclopenthixol
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

…equired, relying solely on poor-quality video monitoring while he was in a padded cell. A more thorough psychiatric assessment considering his full history would likely have resulted in extended hospital treatment, prev…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
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
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

…with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patient with treatment-resistant schizoaffective disorder and obstructive sleep apnoea. While expert ev…

psychiatrycardiologycommunicationsystemclozapine
VICcommunity2023-11-23

Finding into death of Melissa Louise Arbuckle

33y · Female·Mixed drug toxicity (propranolol, oxycodone, diazepam, temazepam, lurasidone, du…

…—she deliberately took her prescribed medications at a truck stop on 9 January 2023. While she received psychiatric treatment from both private psychiatry and community health services post-conviction, the coroner noted…

psychiatrygeneral practicepropranolol
ACTcommunity2025-08-12

Inquest into the death of Stanley McIntyre

63y · Male·pulmonary emphysema

Stanley McIntyre, a 63-year-old man with severe treatment-resistant schizophrenia, died from pulmonary emphasema on 23 June 2021 while subject to a Psychiatric Tr…

psychiatrygeneral practicehaloperidol
SA2005-04-11

Coroner's Finding: POTTER Claire Elizabeth

26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…

…6-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinical concerns include: (1) inadequate ps…

psychiatryemergency medicinecommunicationsystemolanzapine
ACTaged care2021-12-21

Inquest into the death of BRANDON GEOFFREY SAGER

43y · Male·asphyxia due to hanging - suicide

Brandon Sager, 43, died by suicide at the Brian Hennessy Rehabilitation Centre while subject to a psychiatric treatment order. He had a long history of schizophrenia and prior suicide attempts but had shown no sig…

psychiatrysystem
WA2012-01-12

Inquest into the Death of Brennan

38y · Male·Exsanguination due to penetration of arm veins

… with fixed delusions and polysubstance abuse. In the months before death, he became non-compliant with psychiatric medication despite treatment from prison health services. Although reviewed by a mental health nurse sp…

psychiatrycorrectional healthsystemdelaylithium
VIChome2013-10-07

Finding into death of Imanthi Mayakaduwage

17y · Female·Hanging

…t from Sri Lanka, died by suicide via hanging on 5 May 2012. She had documented evidence of significant psychiatric distress from March 2012, including self-harm, researched suicide methods, and meticulously planned her…

general practicepsychiatrydiagnosticcommunication
WAhome2025-01-23

Inquest into the Suspected Death of Benjamin Jacob VAN TRIGT

38y · Male·electrical injury

…an with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requiring hospitalization, with the most r…

psychiatryemergency medicinepaliperidone
178938

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