Coronial

184 results for psychosis (drug-induced)

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
VICmental health2022-03-30

Finding into death of B J

24y · Male·Hypoxic brain injury secondary to hanging

BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…

psychiatryemergency medicinecommunicationsystemquetiapine
VICcommunity2022-12-01

Finding into death of Gabriel Messo

30y · Male·Gunshot wounds to the chest

Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…

psychiatryemergency medicinecommunicationsystem
WAcommunity2022-04-01

Inquest into the Death of Cherdeena Shaye WYNNE

26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…

Ms Cherdeena Wynne, a 26-year-old Noongar Yamatji woman, died from hypoxic ischaemic encephalopathy and bronchopneumonia following cardiac arrest during police restraint on Albany Highway. She was intoxicated with methyl…

psychiatryemergency medicineproceduralcommunicationmethamphetamine
VIC2015-01-30

Finding into death of Matthew Aaron Condie

21y · Male·upper airway obstruction and plastic bag asphyxia

Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable du…

psychiatrypsychologycommunicationsystem
VICmental health2015-07-08

Finding into death of David Allan D'Angelo

30y · Male·Heroin toxicity

David D'Angelo, a 30-year-old Aboriginal man with schizophrenia and polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic relapse. His symptoms improved rapidl…

psychiatryemergency medicinesystemdelayheroin
VIChome2023-07-28

Finding into death of Jackson Desmond David Stawicki

24y · Male·Haemorrhagic shock in the setting of a sharp force injury to the left arm

Jackson Stawicki, 24, died from haemorrhagic shock following a sharp force injury to his left arm while intoxicated with multiple illicit substances. He presented to the ED three times within 24 hours (4-5 September 2020…

emergency medicinepsychiatrycommunicationsystemflualprazolam
WA28 Mar 24

Inquest into the Death of Suzzanne Denise DAVIS

47y · Female·ligature compression of the neck (hanging)

A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…

psychiatryemergency medicinecommunicationsystemmethadone
NSWmental health2025-09-29

Inquest into the death of BQ

23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging

BQ was a 23-year-old Aboriginal woman who died by hanging on the Paringa Ward at Cumberland Hospital while detained as an involuntary mental health patient. She had a complex psychiatric history with schizophrenia and bo…

psychiatryemergency medicinediagnosticcommunication
SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol
QLD2017-10-20

Anthony William Young, Shaun Basil Kumeroa, Edward Wayne Logan, Laval Donovan Zimmer and Troy Martin Foster

Male·Police use of lethal force; coroner found in each case the officers acted approp…

This multi-death inquest examined five police shootings in Queensland (2013-2014) where all deceased had mental health histories. The coroner found officers acted appropriately in each case but made 19 recommendations to…

emergency medicinepsychiatrysystemcommunicationmethamphetamine
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
SAmental health2025-04-17

Coroner's Finding: Furlan, Mark John & Miller, Richard John

50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…

Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…

psychiatryemergency medicinediagnosticcommunicationescitalopram
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
VIChospital2024-05-24

Finding into death of Jacob William Kennedy

36y · Male·Undetermined; three possible mechanisms identified: oversedation with vomiting a…

Jacob Kennedy, a 36-year-old Aboriginal man with polysubstance use disorder and psychiatric illness, died on 4 February 2017 after 11 days as an involuntary inpatient at Frankston Hospital. He was administered multiple s…

psychiatryaddiction medicinemedicationproceduralmethadone
NSWhome2025-06-24

Inquest into the death of Jade

3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…

Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…

paediatricspsychiatrydiagnosticcommunicationquetiapine
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…

psychiatrygeneral practicecommunicationdocumentationsertraline
QLDhospital2025-03-31

Inquest into the death of Jamie Brian Campbell

43y · Male·Hypoxic ischaemic encephalopathy, due to or as consequence of, cardiac arrest of…

A 43-year-old man with methamphetamine toxicity was restrained by police and given two doses of droperidol by paramedics who failed to recognize he was critically unwell. The first dose was clinically indicated, but the …

emergency medicinetoxicologydiagnosticmedicationmethamphetamine
WAprison2025-09-16

Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…

psychiatrypsychologysystemcommunicationamitriptyline
NSWprison2023-07-14

Inquest into the death of GS

43y · Male·Hanging

GS, a 43-year-old man with complex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in Goulburn Correctional Centre after 183 days in custody. The critical fail…

psychiatrygeneral practicediagnosticcommunicationsertraline

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