Coronial

14 results for acute adjustment disorder to custody

QLD2012-08-07

Bucknall, David John

41y · Male·Hanging

…l Health Service due to resource limitations. His psychiatrist provided good care and found no evidence of acute deterioration before death. The immediate trigger was a visit from his former partner on 13 March 2010, th…

psychiatrygeneral practicesystemdelaymirtazapine
WA2019-01-07

Inquest into the Death of Ali JAFFARI

Male·thermal injuries (burns)

…gh the Psychological Support Program, including psychiatric review and monitoring. He was diagnosed with adjustment disorder related to prolonged detention, loss of his protection visa, and fear of deportation to Afghani…

psychiatrypsychologysystemolanzapine
SAmental health2023-09-20

Coroner's Finding: Chessell, David Edward

43y · Male·compression of the neck due to hanging

A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…

psychiatryemergency medicinesystemcommunicationmirtazapine
VIC2012-09-21

Timothycaseypart1 127708

29y · Male·hanging

…gistrar Dr S T urgently requested psychiatric consultant Dr A W review Casey for possible admission to the Acute Assessment Unit, but Dr A W never saw him. Without proper psychiatric review, Casey's suicide risk was dow…

psychiatrycorrectional healthdiagnosticcommunicationheroin
SAmental health2011-07-13

Coroner's Finding: FARMER John Sydney

34y · Male·hanging

John Sydney 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 e…

psychiatryemergency medicinediagnosticcommunicationcitalopram
VIC2022-10-10

Finding into death of Muhammad Jaffar Hassan

45y · Male·Plastic bag asphyxia

Muhammad Jaffar Hassan, aged 45, died in custody at Metropolitan Remand Centre by plastic bag asphyxia on 9 October 2018. He was remanded for murder follo…

psychiatryforensic medicinesystemcommunication
QLD2025-09-08

Inquest into the death of Gina Valera

49y · Female·Hanging

…The case highlights challenges in predicting suicide risk, the importance of timely psychiatric review in custody, and the limitations of risk assessment in newly incarcerated first-time offenders under acute psychologi…

psychiatrycorrectional healthcommunicationsystemmirtazapine
WA2005-01-14

Inquest into the Death of Hendrik Jan Groothedde

39y · Male·Ligature compression of the neck (hanging)

…ea Prison, died by ligature compression of the neck (hanging) on 31 January 2003. He had been admitted to custody in December 2002 following stabbing an ex-girlfriend. Prior psychiatric assessment at Graylands Hospital …

psychiatrycorrectional healthcommunicationsystemantidepressants
WA2019-05-02

Inquest into the Death of Fazel CHEGENI NEJAD

34y · Male·ligature compression of the neck

Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…

psychiatrygeneral practicesystemcommunicationmirtazapine
NSWprison2025-09-10

Inquest into the death of RD

70y · Male·death by hanging, self-inflicted

…d was subsequently treated with antidepressants and psychiatric care, achieving stability. Upon remand in custody in December 2019, Justice Health obtained limited medical records that omitted his psychiatric history, t…

psychiatrygeneral practicecommunicationsystemsertraline
WA2023-12-21

Inquest into the Death of Shane Nathan ROBERTS

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

…er his death. The MHT operated with only 2-3 nurses per shift and a psychiatrist 4 days weekly for 130-150 acutely unwell prisoners. Critical missed opportunities included failure to follow up when he didn't attend appo…

correctional healthgeneral practicesystemdelaycitalopram
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy ca…

neurologypsychiatrydiagnosticcommunicationvigabatrin
SA2006-09-25

Coroner's Finding: BROOKS Neil James and FOSTER Tracy Jayne

43y · Male·suffocation by plastic bag (Neil Brooks); neck compression due to strangulation …

Two deaths investigated in joint inquest: Tracy Jayne Foster died by strangulation in December 2002; Neil James Brooks, her partner charged with her murder, died by suffocation while on remand in May 2003. The coroner id…

psychiatrycorrectional healthcommunicationsystemzopiclone
QLDhome2021-06-15

Bradford, Teresa and Bradford, David - Non-inquest findings

40y · Female·Head injuries inflicted by axe blows in context of intimate partner domestic abu…

…es despite victim repeatedly expressing fear. Ms Bradford was never informed of her abuser's release from custody. Better integrated safety planning, victim-centred risk assessment, and information sharing could have im…

general practicepsychiatrycommunicationsystemwarfarin

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