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NSWmental health2016-02-05

Inquest into the death of SS

48y · Male·hanging, intentionally self-inflicted

SS, a 48-year-old male with treatment-resistant depression and chronic suicidal ideation, died by hanging in Boronia Park, NSW in June 2014. He was admitted to Gosford Hospital Mental Health Unit in late May 2014 as an i…

psychiatrycommunicationsystemlithium
WAhospital2016-02-05

Inquest into the Death of Pauline Margaret DODD

51y · Female·Ischaemic heart disease

Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…

psychiatrycardiologydiagnosticolanzapine
TASmental health2016-01-29

Coroner's Finding: Mr D

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

A 57-year-old European-born man died 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 …

psychiatrygeneral practicecommunicationsystemescitalopram
VIChome2016-01-18

Finding into death of Dean Wayne Wright

30y · Male·Mixed drug toxicity (codeine, tramadol, oxazepam, diazepam)

Dean Wright, a 30-year-old man with bipolar disorder, schizophrenia, anxiety and opioid dependence, died from mixed drug toxicity involving codeine, tramadol, oxazepam and diazepam. He systematically obtained prescriptio…

general practicepsychiatrysystemcommunicationcodeine
VIChome2016

Finding into death of Alexander James McCulloch

35y · Male·Complications of morbid obesity in a man with cardiomegaly and schizophrenia

Alexander McCulloch, a 35-year-old man with schizophrenia, morbid obesity (BMI 45), and cardiomegaly, was found dead in bed. Autopsy attributed death to complications of morbid obesity with cardiomegaly and schizophrenia…

psychiatrygeneral practicecommunicationsystemfluphenthixol decanoate
VICmental health2016

Finding into death of Rebecca Victoria Poke

29y · Female·global cerebral ischaemic injury in the setting of neck compression

Rebecca Poke, a 29-year-old woman with borderline personality disorder, died by suicide while an inpatient in Ward E of Casey Hospital on 2 September 2015. She had been admitted following a paracetamol overdose and was o…

psychiatryintensive caresystemvenlafaxine
VICcommunity2016

Finding into death of XY

58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…

A 58-year-old man with chronic depression, anxiety and personality disorders died from combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propranolol, diazepam) after presenting to ED with suicidal…

psychiatryemergency medicinediagnosticcommunicationeucalyptus oil
VIChospital2016

Finding into death of Zakiya Crystal Lisa Thomas

15y · Female·Hanging

Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…

psychiatrypaediatricscommunicationsystemcitalopram
WAmental health2015-12-31

Inquest into the Death of Michael Ronald THOMAS

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

Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Death of Stephen Colin ROBSON

Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…

Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…

psychiatryemergency medicinediagnosticcommunicationclozapine
WAmental health2015-12-31

Inquest into the Death of Ruby Natasha NICHOLLS-DIVER

Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…

Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…

psychiatryemergency medicinecommunicationdiagnosticantidepressants
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
WAmental health2015-12-31

Inquest into the Death of Anthony Ian EDWARDS

Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…

Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…

psychiatryemergency medicinediagnosticcommunicationantidepressants
WAmental health2015-12-31

Inquest into the Deaths Alma Street Centre

Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…

Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…

psychiatryemergency medicinediagnosticcommunicationantidepressants
VICmental health2015-12-20

Finding into death of Danny Wayne Feschuk

46y · Male·Cardiomegaly in the setting of hypoventilation syndrome in an obese man with sch…

A 46-year-old man with schizophrenia, COPD, hypoventilation syndrome, obesity and cardiomegaly died suddenly on a psychiatric inpatient unit from a cardiac arrhythmia. He had experienced multiple respiratory crises requi…

psychiatryrespiratory medicineoxycodone
VIC2015-12-18

Finding into death of Odisseas Vekiaris

29y · Male·Unascertained causes on a background of agitated delirium state

A 29-year-old man with a 12-year history of mental illness died in police custody during transport to a police station. He had stopped taking his antipsychotic medication (Risperidone 4mg daily) following GP advice to re…

general practicepsychiatrycommunicationsystemrisperidone
NSW2015-12-18

Inquest into the death of Officer A

43y · Female·External neck compression due to self-inflicted hanging

A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…

psychiatrypsychologydiagnosticsystemprescription medication
VIChome2015-12-16

Finding into death of Andrew Stanyer

37y · Male·Hanging

Andrew Stanyer, a 37-year-old male with significant life stressors, died by hanging after police attendance at a family violence incident. He had previous suicide attempts (2000, 2009), depression treated with sertraline…

psychiatrygeneral practicesystemcommunicationsertraline
QLDcommunity2015-12-14

Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra

42y · Male·Anthony Young: multiple gunshot wounds to the body and arm; David Young: multipl…

Anthony Young, aged 42, shot by police after fatally stabbing his brother David and David's partner Louise. Anthony had deteriorating mental health including paranoia, substance use, and lack of psychiatric engagement de…

psychiatryforensic medicinediazepam
VIChospital2015-12-09

Finding into death of Benjamin David Johnston

36y · Male·Global hypoxic brain injury due to hanging

Benjamin Johnston, a 36-year-old male, died by hanging after six weeks of varenicline (Champix) treatment for smoking cessation. Two weeks before death, his partner noted significant behavioral changes: withdrawal, irrit…

general practicepsychiatryvarenicline

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