Coronial

366 results for psychiatric admission assessment

VIChospital2026-05-19

Finding into death of Edward Timothy Peterson

25y · Male·Head injury sustained on impact with a train

Edward Timothy Peterson, aged 25, was involuntarily admitted to Maroondah Hospital's psychiatric unit on 11 February 2021 with first episode psychosis. Clinical care by psychiatrist Dr C. was appropri…

psychiatrysystempaliperidone
VICmental health2019-09-19

Finding into death of Vanna Vassallo

68y · Female·Complications of a right subdural haemorrhage (palliated), sustained in a fall

…rrhage sustained in a fall at an aged mental health inpatient unit. She had sustained three falls during admission, with the final unwitnessed fall on 14 May 2017 resulting in massive intracranial bleeding. Clinical ass…

psychiatrygeriatric medicinepossibly_preventablefluphenazine decanoate
QLDmental health2007-06-20

Liddell, Matthew John

28y · Male·hypoxic encephalopathy secondary to hanging

…t-traumatic stress disorder and depression following the 1998 HMAS Westralia fire, died by hanging in a psychiatric hospital. He had been admitted on 8 November 2003 after separation from his de facto wife triggered acu…

psychiatryemergency medicinecitalopram
VICcommunity2013-01-16

Finding into death of Mark Robert Scott

41y · Male·Effects of Fire

…pressive illness, was admitted to Frankston Hospital on 15 July 2011 following suicidal ideation. During admission, he disclosed to his sister that he would take his life by setting fire to himself and his car. He was d…

psychiatrygeneral practicedelaycommunicationmethadone
WAhospital2018-09-10

Inquest into the Death of Theodore Herbert Eric JOHANSEN

50y · Male·Drowning

…d plan to drown himself using a block and chain. He was appropriately referred to Peel Health Campus for assessment. The ED doctor referred him to a psychiatric liaison nurse, who assessed him as low risk after he denied…

psychiatryemergency medicinediagnosticcommunicationamitriptyline
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…nd financial crisis. In October 2023, he presented with acute mania and psychosis, requiring compulsory psychiatric hospitalization. After three weeks inpatient treatment, he was discharged to community care and his tre…

psychiatryemergency medicinediagnosticcommunicationolanzapine
TASmental health2019-01-04

Coroner's Finding: Roberts, Nigel Douglas

55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…

…ne) in the presence of advanced emphysema and acute bronchopneumonia. He was admitted to Spencer Clinic psychiatric inpatient unit following an assault on staff at Karingal nursing home. During his 23-hour hospital admi…

psychiatryemergency medicinemedicationdiagnosticclozapine
NTmental health2015-01-21

Inquest into the death of Anthony Faulkner

42y · Male·Sudden cardiac death in the context of schizophrenia

…renia (formerly diagnosed as bipolar disorder), died suddenly on 23 September 2013 while an involuntary psychiatric patient at Cowdy Ward, Royal Darwin Hospital. He had been admitted on 8 August 2013 and was in the proc…

psychiatrygeneral medicinepaliperidone
VICmental health2013-08-23

Finding into death of James Falzon

65y · Male·Hanging

James Falzon, a 65-year-old man with psychotic depression admitted to Peter James Centre psychiatric ward, died by suicide via hanging. He had been assessed as high-risk and was on 15-minute observations …

psychiatryforensic medicinesystemproceduralrisperidone
SAhospital2019-03-25

Coroner's Finding: NICHOLSON James

65y · Male·hypoxic ischaemic encephalopathy complicating hanging

…he next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included: misdiagnosis of the underlying steroid-induced syndrome, failure to…

oncologypsychiatrydiagnosticcommunicationdexamethasone
NTcommunity2011-10-11

Inquest into the death of Aaron Nathan Stagg

28y · Male·hanging

…homicide risk. Despite initial case management, he disengaged by mid-2009. When re-engaged in late 2009, assessment identified paranoid delusional thinking. Dr K. recommended voluntary hospital admission on 2 March 2010,…

psychiatrypsychologysystemrisperidone
SAhome2000-07-07

Coroner's Finding: EDGELL Debby

39y · Female·neck compression due to hanging

…ultiple past suicide attempts died by hanging at home on 11 February 1998. She had been discharged from psychiatric hospital 7 days earlier after a brief admission. On the evening of her death, she called a mental healt…

psychiatryemergency medicinesystemvenlafaxine
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted…

psychiatryintensive caresystemcommunicationrisperidone
VIChospital2022-05-04

Finding into death of Marlene Sako

25y · Female·self-immolation

…reats of self-harm and suicide attempts. Despite a pattern of escalating presentations over months, the psychiatric assessment failed to obtain collateral information from her family, who were present and able to provid…

emergency medicinepsychiatrydiagnosticcommunicationalcohol
NSWmental health2017-07-11

Inquest into the death of CCW

68y · Female·Hypoxic Ischaemic Encephalopathy as a result of Hanging

…al of self-harm intent and preoccupation with delusions about her husband. She was admitted to an acute psychiatric unit but placed in an open ward (rather than the planned observation area) due to bed unavailability. N…

psychiatrygeriatric medicinecommunicationsystemquetiapine
VICcommunity2021-04-14

Finding into death of JJ

70y · Male·Hanging

…er than depression. Following a serious overdose attempt, he was admitted to psychiatry, improved during admission, and was discharged with antidepressant therapy and community follow-up. However, he ceased taking his p…

psychiatryendocrinologycommunicationsystemvenlafaxine
TAShospital2022-02-28

Coroner's Finding: Hassanloo, Saeed

27y · Male·traumatic injuries and/or drowning from jumping from Tasman Bridge

A 27-year-old Iranian asylum seeker died by suicide after jumping from Tasman Bridge. He had a complex psychiatric history including depression, anxiety, and adjustment disorder, with multiple self-harm episodes. His s…

psychiatryemergency medicine
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

…nd three prior suicide attempts, died by hanging in Brisbane Women's Correctional Centre nine days after admission on remand for attempted murder. She had been hospitalised two weeks prior with suicidal ideation but dis…

psychiatrycorrectional healthcommunicationsystemmirtazapine
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

…y Farmer, aged 34, died by hanging at his home on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days earlier fo…

psychiatryemergency medicinediagnosticcommunicationcitalopram
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

…n a regular cell that had not been searched and contained a razor blade fragment. Key clinical lessons: psychiatric review should follow self-harm requiring surgical intervention; mental health assessment should not rel…

psychiatryemergency medicinediagnosticsystem
1891019

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