Coronial

177 results for severe anxiety

WAhome2016-07-21

Inquest into the Deaths of Jessica Rose CUZENS and Jane Lesley Margaret CUZENS and Heather GLENDINNING

46y · Female·Ms Glendinning: multiple sharp force injuries (suicide); Jane Lesley Margaret Cu…

Heather Glendinning, severely mentally ill with chronic paranoid delusions exacerbated by cannabis abuse and stress from family court …

psychiatrygeneral practicecommunicationsystemcannabis
NSWhome2024-12-12

Inquest into the death of Ms K

43y · Female·suffocation

Ms K, aged 43, was killed by her husband through suffocation on 7 March 2017 after years of coercive control, physical violence, and emotional abuse. A critical police response on 17 August 2016 when Ms K reported car va…

general practicepsychologycommunicationsystemalcohol
VICmental health2012-03-13

Finding into death of Matthew Spalding

28y · Male·neck compression subsequent upon hanging

Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …

psychiatryemergency medicinecommunicationsystemaripiprazole
NSW2024-05-17

Inquest into the death of Vicki Higgins

48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…

… She was never medically screened despite being received during an unprecedented COVID-19 outbreak causing severe staff shortages. Throughout her custody, she reported nausea, vomiting, inability to eat or drink, and req…

general practicegastroenterologydiagnosticdelay
SApsychiatric ward2009-10-01

Coroner's Finding: RODRIGUEZ Antonio

49y · Male·hanging (suicide)

…discharge from Ward B8 (psychiatric short-stay unit) at Royal Adelaide Hospital. He had been admitted with severe depression and active suicidal ideation. The coroner found his discharge was premature and inappropriate. …

psychiatrydiagnosticcommunicationolanzapine
QLDcommunity2010-12-16

Bell, Jennifer Elizabeth

34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…

Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide …

psychiatrygeneral practicecommunicationsystemstillnox
SAhospital2005-06-03

Coroner's Finding: SORENSEN Ruth Bengta Maria

69y · Female·faecal peritonitis due to small bowel obstruction and perforation due to periton…

A 69-year-old woman presented to the Emergency Department with abdominal pain and vomiting. The doctor did not take adequate history, perform thorough physical examination, or order basic investigations including blood t…

emergency medicinesurgerydiagnosticcommunicationprochlorperazine
TAS2023-09-01

Coroner's Finding: Hunt, Paul George; Reynolds, Paul James; Darke, Simon Graham; Cooke, Robert Anthony

Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…

…on duty; his death appeared unrelated to policing. Sergeant Cooke died by hanging after years of untreated severe PTSD from cumulative trauma exposure. The coroner identified failures in welfare protocols, fatigue manage…

psychiatrypsychologysystemcommunicationpseudoephedrine
NSWhospital2025-11-17

Inquest into the death of Brooke Tiddy

32y · Female·Cardiac arrest due to hypoxia caused by dynamic hyperinflation arising from comp…

…rway caused dynamic hyperinflation, leading to cardiac arrest. The autopsy revealed previously undiagnosed severe subglottic stenosis. Earlier recognition would have allowed joint surgical-anaesthetic planning or procedu…

bariatric surgeryanaesthesiadiagnosticcommunicationsevoflurane
NTcommunity2026-01-23

Inquest into the death of Kumanjayi Johnson

45y · Male·Environmental exposure and dehydration

A 45-year-old Aboriginal man with severe cognitive impairment (6.5-year-old equivalent English comprehension), traumatic brain injury, epilepsy and…

geriatric medicinepsychiatrycommunicationsystem
WAAugust 2024

Inquest into the Death of Matthew Francis LEACH

50y · Male·ligature compression of the neck (hanging)

…n coordinating custodial and health staff. The coroner found no individual clinician error but highlighted severe resource constraints, overcrowding, and the absence of any psychiatrist at Hakea Prison at the time of inq…

psychiatrypsychologysystemdelayvenlafaxine
SAhospital2008-05-23

Coroner's Finding: KROL Riley

0y · Male·hypoxic ischaemic encephalopathy

…ivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus developed severe, sustained bradycardia lasting approximately 30 minutes before delivery. The emergency caesarean section d…

obstetricsanaesthesiacommunicationsystemcervedil
SAhospital2018-03-05

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…

Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…

psychiatrypsychologydiagnosticcommunicationquetiapine
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

…mith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered with antidepressants and lithium, but his firearms lic…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
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
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

…tion risk assessment (particularly cumulative harm analysis), inadequate mental health services with CAMHS severely under-resourced, media reporting breaching Mindframe guidelines following Child 3's death possibly contr…

psychiatrypaediatricssystemcommunicationlamotrigine
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

…mote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government agencies. Fionica was pursued by an adult male who threatened her fam…

paediatricspsychiatrydiagnosticcommunicationalcohol
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