Coronial

81 results for adolescent depression

NSWcommunity2015-01-23

Inquest into the death of XY

17y · Female·multiple blunt force injuries after being struck by a train

…missions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, and depression. The Coroner found that care provided by Hornsby Hospital and CAMHS was appropriate and compliant with N…

psychiatryemergency medicinefluoxetine
TAScommunity2016-09-30

Coroner's Finding: Westbrook, Eden Jayde

15y · Female·asphyxia due to hanging

…e Westbrook, a 15-year-old high school student, died by suicide on 17 February 2015. She had experienced depression for some time without formal diagnosis, had a history of self-harm and suicide attempts, and had explici…

psychiatrypaediatricssystemdelay
WAhospital2016-03-24

Inquest into the Death of Jesse Richard DELLAR

17y · Male·ligature compression of the neck (hanging)

Jesse Dellar, a 17-year-old with a history of ADHD, learning disability, depression, and childhood sexual abuse, was admitted to Albany Regional Hospital on 23 November 2010 after intentio…

psychiatrygeneral practicediagnosticsystematomoxetine
VICcommunity2010

Finding into death of Mikael Chandra Rohan

14y · Male·head injuries when struck by a train

… 2010 with suicidal ideation was assessed by a psychiatric nurse (Nurse Sebille) rather than a child and adolescent psychiatrist as requested by his GP. The assessment was rated as low risk and discharged. Care became fr…

psychiatrygeneral practicediagnosticcommunicationtemazepam
NSWcommunity2015-01-30

Inquest into the death of Alec Samuel MEIKLE

17y · Male·Hanging (self-inflicted)

…n October 2008. The coroner found the workplace environment was a substantial contributing factor to his depression. While NSW practitioners provided appropriate care, the coroner lacked jurisdiction to determine finding…

psychiatrygeneral practicesystemfluoxetine
VICcommunity2017-04-05

Finding into death of KP

15y · Male·Hanging (redacted in original but indicated by reference to method of suicide)

A 15-year-old boy with depression died by suicide. He had a difficult relationship with his parents and was reluctant to engage with menta…

psychologypsychiatrycommunicationsystem
WAhome2014-10-17

Inquest into the Death of Ethan (Subject to a Suppression Order)

15y · Male·Ligature compression of the neck (hanging)

A 15-year-old Aboriginal boy in foster care died by suicide following apparent impulsive response to adolescent boundary conflicts. Despite stable, loving foster placement since age 4, Ethan remained neurologically v…

psychiatrypsychologymelatonin
NThome2026-06-19

Inquest into the death of RL

17y · Male·Suicide by self-inflicted hanging

…isk; questionable discharge decision on 2 November 2023 (four days before death) regarding assessment of depression severity, with concerns that adult assessment criteria were applied rather than adolescent-specific pres…

psychiatrypsychologycommunicationdiagnostic
VIChospital2022-09-07

Finding into death of Mr AB

17y · Male·Hypoxic ischaemic encephalopathy due to hanging

…tient care. He had complex medical needs including chronic back pain, spinal fusion, post-viral fatigue, depression, anxiety, and gender dysphoria. Critical clinical lessons include: (1) recognition that suicide can be i…

psychiatryemergency medicinesystemcommunicationquetiapine
VIChome2020-09-28

Finding into death of JC

17y · Male·Hanging

… breach of the FVIO, and he died by suicide within approximately one hour. Key clinical lessons include: adolescent family violence requires specialist, non-punitive responses rather than exclusionary orders; youth exclu…

psychiatryemergency medicinesystemcommunicationdiazepam
NSWcommunity2011-07-22

01ab 092558 redacted

15y · Male·multiple blunt force injuries as a result of being hit by a train

AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered f…

general practicepsychiatrymedicationcommunicationescitalopram
TAScommunity2022-01-28

Coroner's Finding: AZ 2022 TASCD 60

16y · Male·Multiple blunt traumatic injuries from fall from height

A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria aft…

psychiatrycommunicationdiagnosticfluoxetine
VIChome2013-10-07

Finding into death of Imanthi Mayakaduwage

17y · Female·Hanging

…iculously planned her death. Key clinical lessons: (1) early recognition of psychiatric warning signs in adolescents is essential—Imanthi displayed depression, self-harm, sleep and appetite disturbance, and social withdr…

general practicepsychiatrydiagnosticcommunication
VIChome2013-04-12

Finding into death of Cody Jackson

15y · Male·asphyxiation by hanging

…al activity. Cody was involved with multiple services including Child Protection, Youth Justice, and the Adolescent Forensic Health Service. Despite psychiatric assessments identifying depression, anger issues, and traum…

psychiatrypsychologysystemdelay
VIChospital2021-05-31

Finding into death of Ms Jane

13y · Female·hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate toxicity

Jane, aged 13, died from hypoxic ischaemic encephalopathy secondary to gamma hydroxybutyrate (GHB) toxicity following accidental overdose. She ingested an estimated 6-9mls of GHB in early June 2017, having used the drug …

emergency medicineintensive caregamma hydroxybutyrate
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

…intervention in infancy/toddlerhood is cost-effective and crucial; mental health services need dedicated adolescent inpatient facilities, outreach models, and coordination; child protection must assess cumulative harm an…

psychiatrypaediatricssystemcommunicationlamotrigine
VICcommunity2010-12-02

Finding into death of DUKE MATAKU TERA

19y · Male·Hanging (intentional suicide)

…uke Mataku Tera, a 19-year-old of Maori descent who died by hanging on 1 May 2007. Duke had a history of depression, substance abuse, anger management issues, and previous suicide attempts. He was under supervision by th…

psychiatrypsychologycannabis
VIChome2020-08-11

Finding into death of Angel Louise Hensgen

13y · Female·Acute paracetamol toxicity

…vention with N-acetylcysteine within 24 hours of overdose could have averted death. Key clinical lesson: adolescent mental health presentations require holistic assessment, active family engagement, documentation of risk…

general practicetoxicologycommunicationsystemparacetamol
VIChome2017-09-21

Finding into death of ALJW

21y · Male·Combined effects of heroin toxicity and plastic bag asphyxia

…ease (Fontan procedure) died from combined heroin toxicity and plastic bag asphyxia. He had a history of depression and suicidality since childhood. In August 2014, during a cardiology review, he misinterpreted prognosti…

cardiologypsychologycommunicationsystemheroin
SAschool2003-10-27

Coroner's Finding: CHAPMAN Michael James

16y · Male·Gunshot wound to the head

A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 Au…

psychiatrygeneral practicediagnosticcommunicationcitalopram

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