Coronial

390 results for mental health deterioration

WAhospital2022-01-06

Inquest into the Death of Louisa Betty RYAN

89y · Female·aspiration pneumonia with respiratory failure complicating major depression with…

…, she was given thickened fluids and medications which she aspirated, causing pneumonia and subsequent deterioration. The coroner found the ECT treatment appropriate given her history of responding well to ECT and poor …

psychiatryanaesthesia
VIChome2022-12-15

Finding into death of Taylor Zachary Oliver

19y · Male·Stab wounds to the neck and chest

…and substance use disorder, died by self-inflicted stab wounds on 1 December 2019. He had been admitted to mental health inpatient care on 18 November 2019 following overdose and suicidal ideation, and discharged 36 hour…

psychiatryemergency medicinecommunicationsystempaliperidone
WAaged care- 11 April 2014

Inquest into the Death of Bill PORTELLI

64y · Male·bronchopneumonia in a man receiving palliative care for terminal cancer of the r…

…umonia (from aspirated vomit) while receiving palliative care at Alma Street Centre. He was an involuntary Mental Health Act patient. The coroner found supervision, treatment and care were exemplary. The deceased refused…

psychiatrypalliative carefentanyl
NSW2022-11-24

Inquest into death of William EPERE

43y · Male·Hanging

…en remanded in custody for 27 days following repeated breaches of a domestic violence order, despite clear mental health deterioration. Although Billy was found to be deceased and unable to be resuscitated, the coroner i…

psychiatrycorrectional healthproceduralsystemescitalopram
VIChospital2021-04-08

Finding into death of Ian Lindsay Gould

64y · Male·Complications of Creutzfeldt-Jakob Disease following a fall

…sual loss was suspected. He developed major depression with suicidal ideation and was admitted to an acute mental health unit. On 7 August, he fell backwards, hitting his head, but was assessed as orientated with no brui…

neurologyophthalmologysystemrivaroxaban
VICcommunity2020-12-09

Finding into death of Maggie Rose Bant

20y · Female·Plastic bag asphyxia with inhalation of helium

… and self-harm died by helium inhalation asphyxia. She had been treated by her GP with antidepressants and mental health referral to a psychologist but never disclosed suicidal ideation despite clinical concerns. Her ex-…

general practicepsychiatrydiagnosticcommunicationsertraline
NSWcommunity2022-08-04

Inquest into the death of Brian Liston

51y · Male·Stab wound to the heart

…cember 2015. Cahill suffers severe treatment-resistant schizophrenia and was found not guilty by reason of mental illness. The inquest examined whether his community mental health care was adequate. Expert evidence from …

psychiatrytoxicologyclozapine
VICcommunity2016-11-29

Finding into death of Phillip Richard Anderson

32y · Male·Complications of mixed drug use

…noted that timely intervention may have prevented death and was disturbed that passengers observed his deterioration without alerting authorities. Key lessons include the importance of bystander awareness and reporting …

psychiatryforensic medicinecommunicationzuclopenthixol
NSW2022-06-23

Inquest into the deaths of Mary Louise NELSON and Rowan NELSON

Female·Multiple Injuries (motor vehicle collision)

… median and collided head-on with a semi-trailer. Both died from multiple injuries. Rowan had a history of mental health issues including a serious suicide attempt in December 2019, but evidence at the time of the collis…

escitalopram oxalate (lexapro) - prescribed antidepressant for rowan
VICcommunity2025-11-28

Finding into death of Niels Gunther Btb: Becker

39y · Male·Unascertained

…died from exposure to the elements. The case demonstrates the challenges of managing patients with serious mental illness in community settings and the importance of robust safety planning for high-risk activities.

psychiatrygeneral practicearipiprazole
SAcommunity2014-03-12

Coroner's Finding: MUNDY Michaela Jayne

15y · Female·neck compression due to hanging

…suicidal ideation, self-harm, and moderate-to-severe depressive symptoms. Despite evidence of clinical deterioration, risk escalation, and concerning features (possible psychosis, dissociation), Hotich assessed risk as …

psychiatrygeneral practicediagnosticcommunicationfluoxetine
NSWcommunity2022-08-02

Inquest into the disappearance and suspected death of Kenneth Klees

37y · Male·Unascertained

… controlled type 2 diabetes, and obsessive-compulsive disorder. In the weeks before his disappearance, his mental health appeared to deteriorate. He travelled alone to Kiama on the day he disappeared, was last seen on CC…

general practicepsychiatrycommunicationsystem
SAhome2024-09-13

Coroner's Finding: Sulley, Matthew Wade

46y · Male·neck compression due to hanging

…deation presentation (2021), and chronic methamphetamine use. Despite appearing compliant and reporting no mental health concerns on 7 March 2022, toxicology revealed cocaine and methamphetamine metabolites at death. An …

forensic medicinepsychiatrycommunicationsystemmethamphetamine
NSWcommunity2026-01-20

Inquest into the disappearance and suspected death of AL

35y · Male·The available evidence does not allow for any finding to be made as to the cause…

A 35-year-old male with extensive mental health history died by intentional self-inflicted means on 13 September 2022 at Vaucluse, NSW. He had mult…

psychiatrypsychology
NSWcommunity2017-07-12

Inquest into the suspected death of missing person Benjamin Stephens

23y · Male·Unable to be determined from available evidence

…toms consistent with schizophrenia including paranoia, delusions, and social withdrawal. He was treated by mental health services and prescribed antipsychotic medications but became non-compliant, ceasing medications due…

psychiatrygeneral practicesystemdelayquetiapine
NSW2020-01-24

Inquest into death of MW

52y · Male·Hanging

… management policies were appropriately followed. There was no documented evidence of suicidal ideation or mental health deterioration between mid-April and his death on 5 May. The coroner concluded staff had no reason t…

general practicepsychiatrymirtazapine
NSWhospital2024-01-30

Inquest into the death of Subash Subedi

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

… between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 with acute mental health symptoms, including disorientation and dehydration following cannabis use and a period of erratic b…

emergency medicinepsychiatrycommunicationsystemolanzapine
NSWcommunity2021-06-08

Inquest into the death of Zhong Liu

54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…

54-year-old man with schizophrenia died after acute mental health crisis during police response. Contributing factors included: arrhythmogenic cardiomyopathy (undete…

psychiatrygeneral practicemedicationcommunicationdoxepin
NSWhome2022-09-13

Inquest into the death of Ian Fackender

47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…

…nadequate risk assessment and planning by police before and during the operation; miscommunication between mental health services and police about the sword possession and staffing availability; premature and unnecessary…

psychiatryforensic medicinecommunicationsystemaripiprazole
VIChospital2025-01-10

Finding into death of William Thomas Gourley

39y · Male·Effects of fire (self-immolation)

William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on …

emergency medicinepsychiatrydiagnosticcommunicationolanzapine
1891020

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