Coronial

346 results for mental health distress

SA2012-11-14

Coroner's Finding: Heyward Neil Wills

53y · Male·neck compression due to hanging

…t, he consistently denied suicidal intent. A chaplain raised serious safety concerns after an emotionally distressing incident in December 2008, but reported encountering an abusive response from prison officers; the Dep…

psychiatrycorrectional healthsystemcommunication
VICcommunity2025-03-04

Finding into death of Andrea Dorothy Milner

55y · Female·Multiple injuries sustained in a train incident

… clinical failures. The death highlights the complexity of assessing suicide risk in patients with chronic mental health conditions and communication difficulties.

psychiatrypsychologyescitalopram
NSW2022-03-24

Inquest into the death of NG

Male·consistent with the history of hanging

…custody on his first remand in prison. He had been charged with serious offences and refused bail. Justice Health conducted initial screening, diagnosed situational crisis with low self-harm risk, and maintained monitori…

psychiatrygeneral practice
WAhome2016-02-15

Inquest into the Death of John Stephen PASSMORE

53y · Male·ligature compression of the neck (hanging)

…ignificant improvement. The treating team faced an ethical dilemma: continued hospitalisation was causing distress without clinical benefit, while discharge risked inadequate community support. The decision to discharge …

psychiatryrehabilitation medicineolanzapine
TAShome2020-07-16

Coroner's Finding: Alsop, Olaf Paul

54y · Male·asphyxia due to hanging

A 54-year-old man with long-standing mental health issues, substance use disorder, and terminal lung cancer died by hanging. He had a history of suici…

general practicepalliative carecodeine
VIChome2012-02-14

Finding into death of David Travaglia

27y · Male·carbon monoxide poisoning

…e profound psychological burden on primary carers of profoundly disabled individuals and the importance of mental health support for such caregivers.

benzodiazepines
WA2002-04-12

Inquest into the Death of Scott Davidson

26y · Male·Ligature compression of the neck (Hanging)

…ner with psychiatric training, identified concerning psychotic behaviours and recommended reassessment, no mental health professional reviewed him on 4 June 2000. He died by ligature strangulation with a stereo cord. The…

psychiatrycorrectional healthdiagnosticcommunicationolanzapine
WAcommunity2021-05-11

Inquest into the Death of Janice Ann CROFT

64y · Female·phosphine toxicity from deliberate ingestion of aluminium phosphide fumigation p…

…ngested the pellets before apprehension. The coroner found police actions were statutorily justified under mental health legislation once Ms Croft refused voluntary departure, and none of the agencies involved acted inap…

emergency medicinetoxicologysystemlithium
NThome2011-03-15

Inquest into the death of Dwayne Joseph Berto

23y · Male·Suicide by hanging

…ging in his home in Darwin on 25 August 2010. He was highly intoxicated (blood alcohol 0.268%) and deeply distressed. Contributing factors included recent family separation, arguments with his father about a car purchase…

psychiatryemergency medicinealcohol
VIChome2008-05-16

Finding into death of Brodie Panlock

19y · Female·Head injury

…y management and coworkers at her workplace cafe. She had a vulnerable emotional state exacerbated by an unhealthy relationship with her manager. The coroner found that her employer was aware of the bullying but failed t…

systemcommunicationalcohol
WAcommunity2019-08-01

Inquest into the Death of Matthew James BALE

38y · Male·Unascertained; death in the waters of the Indian Ocean off Rottnest Island

…ical lessons include recognising the vulnerability of individuals with concurrent substance use disorders, mental health conditions, and acute intoxication, and the importance of risk assessment and safety planning in su…

psychiatryaddiction medicinecitalopram
NSW2019-04-03

Inquest into the disappearance and suspected death of Luxing Li

28y · Male·unknown

…. He had recently failed an accounting exam for the third time and sent a final text suggesting emotional distress, but had no documented mental health history. The coroner noted CCTV cameras and increased fencing have s…

NSW2020-12-03

Inquest into the death of George CAMERON

81y · Male·plastic bag asphyxia

…n custody three days earlier after arrest. A Reception Screening Assessment on arrival identified physical health issues warranting monitoring and a low Kessler psychological distress score (10-19), with no reported suic…

psychiatryemergency medicinesystemdelay
VIC2022-04-19

Finding into death of Mr BB

29y · Male·Multiple injuries sustained in a fall from a height

…s and work stress. No prior family violence was reported. The coroner found no prevention opportunities in healthcare provision. Police communication protocols were reviewed; while a phone triangulation was considered, t…

general practicepsychologydiagnosticdelay
VIChome2011-08-10

Finding into death of B

17y · Male·Hanging

…and many suicides occur without identified triggers. The coroner emphasized that while known risk factors (mental illness, suicidal ideation, relationship breakdown) are common, they don't reliably predict suicide. Unive…

NSWhome2016-08-11

Inquest into the deaths of Mr TK and Mrs TK

Female·Mrs TK: gunshot wounds to the head and left forearm inflicted by Mr TK; Mr TK: s…

…ed a firearm under a sporting permit for target shooting. After posting a Facebook message expressing his distress about the situation, Mr TK fatally shot Mrs TK (gunshot wounds to head and forearm) before shooting himse…

VIChospital2018-02-28

Finding into death of Samuel Carl Johansen

36y · Male·Multi-organ failure complicating injecting drug use

A 36-year-old man with a 13-year history of schizophrenia and substance abuse was admitted involuntarily to a psychiatric unit on 15 September 2012 after community deterioration. He improved over several weeks and was tr…

psychiatryintensive carecommunicationdelayheroin
SAcommunity2007-12-12

Coroner's Finding: BAUMANIS Bronislawa Sonia

84y · Female·ischaemic heart disease

…itially refused hospital admission due to fears of nursing home placement. Her GP appropriately obtained a Mental Health Act detention order when she refused transport despite clinical necessity. During transfer to the a…

general practiceemergency medicineadrenaline
VIChome2020-06-15

Finding into death of Gordon Malcolm Wallace

71y · Male·Plastic bag asphyxia and argon gas inhalation

…ificantly impact psychological wellbeing; document discussions about end-of-life wishes thoroughly; ensure mental health screening in patients with multiple comorbidities and functional decline. The case highlights syste…

nephrologyoncologysystemargon gas
WAcommunity2022-08-17

Inquest into the Death of Quoc Xuan TRAN

36y · Male·Immersion (drowning)

…2019 with accommodation concerns; staff conducted a risk assessment documented as non-urgent with no acute mental health issues identified. The coroner found appropriate clinical care was delivered within available resou…

psychiatryemergency medicinesystempaliperidone
1891018

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