Coronial

361 results for critical illness

WAcommunity2016-08-22

Inquest into the Death of Ewan Louis WILLIAMSON

14y · Male·severe heatstroke complicating a recent viral illness with focal myocarditis

… while hiking in extreme heat (40°C+) at Cape Range National Park. He had recently recovered from a viral illness. His father made navigation errors that prolonged their exposure. Police failed to immediately dispatch a…

emergency medicineparamedicinecommunicationdelay
QLD2008-03-17

Waite, Thomas Dion; Huynh, Mieng; Jacobs, James Henry; Gear, James Michael

Unknown·gunshot wounds; multiple deaths during police interventions with mentally ill in…

…ber 2003 and February 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the officers reasona…

psychiatryemergency medicinediagnosticcommunicationantipsychotic medications
TAShospital2022-03-18

Coroner's Finding: Collis, Mary

73y · Female·pulmonary embolus

Mary Collis, a 73-year-old woman with bipolar disorder and type 2 diabetes, died from pulmonary embolus whilst an inpatient at Launceston General Hospital on 15 June 2020. She was admitted after becoming unconscious at h…

intensive carepsychiatry
VIChome2019-02-15

Finding into death of Seker Yildiz

59y · Female·Sharp force injuries to the neck

…ursun Yildiz, using a small axe at their home in Dallas, Victoria. The perpetrator had undiagnosed mental illness characterised by delusional beliefs that his life was at risk and auditory hallucinations. No discernible…

general practicepsychiatrydiagnosticparacetamol
NSWhome2014-01-10

Inquest into the death of Chloe HEUSTON

36y · Female·multiple stab wounds to the trunk inflicted by a known person

…loe Heuston, aged 36, died from multiple stab wounds inflicted by a known person with an untreated mental illness. The coroner found that ambiguities in the Mental Health Act 2007 regarding scheduling criteria may have …

psychiatrysystem
NSWcommunity2024-04-18

Inquest into the death of Baby Q

<1y · Female·unascertained

…eless, were known to child protection and police in NSW and Queensland with complex mental health issues. Critical failures included Queensland DCSSDS inadequately assessing an August 2018 notification of parental aggres…

paediatricspsychiatrysystemcommunication
VICcommunity2022-05-26

Finding into death of Christopher Polden

Unknown·Sally-Anne Wills: multiple stab wounds to the chest; Christopher Polden: single …

…and paranoid ideation following family separation. While insufficient evidence definitively linked mental illness to the attacks, the coroner could not exclude psychiatric illness as a contributing factor. The police sh…

forensic medicineemergency medicine
VICcommunity2020-11-27

Finding into death of Nicholas Daniel Ficarra

26y · Male·unascertained; suspected suicide by firearm

…Victoria. He had a history of substance abuse (heroin, OxyContin, cannabis) from age 21 and severe mental illness from 2009, including paranoid ideation and command hallucinations suggesting suicide. He was prescribed a…

psychiatrygeneral practicesystemdelayheroin
VIChome2013-03-05

Finding into death of Peter Harold Ralph Quin-Conroy

49y · Male·Gunshot injury to the head

…ng command hallucinations instructing self-harm. He was treated by Dr W. (GP) and Dr G. (psychiatrist). A critical system failure emerged: Dr W. was aware of Quin-Conroy's firearms license (having written a supporting le…

general practicepsychiatrycommunicationsystem
WAhospital2014-12-30

Inquest into the Death of Gheorghe Gruici

71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…

…morbidities including COPD, early gastric carcinoma (treated with gastrectomy), diabetes, and psychiatric illness. His complex medical and mental health needs were managed through prison medical staff and external hospi…

general medicinenephrologyomeprazole
SA2016-09-22

Coroner's Finding: HENEKER Scott Maxwell

36y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restrain…

…ic symptoms (paranoia, delusions) likely triggered by amphetamine use. He had signs of undiagnosed mental illness and was showing concerning behavioral changes in the weeks prior. Critical clinical lessons include: the …

psychiatryemergency medicinedelaycommunicationmethamphetamine
VICcommunity2017-10-24

Finding into death of Glenn Albert Sanders

48y · Male·Injuries sustained in an explosion

…ed from injuries sustained in explosions on his property during a police siege. Sanders had severe mental illness (Delusional Disorder/Schizophrenia), polysubstance abuse, and had rigged his house and farm buildings wit…

psychiatrygeneral practicecommunicationsystemrisperidone
WAmental health2014-04-11

Inquest into the Death of Amanda Alison GILBERT

47y · Female·bronchopneumonia in context of ischaemic heart disease, chronic renal failure, a…

…ds Hospital since 1987. The coroner found that staff provided appropriate care given available resources. Critical deficits existed for her first ten years: she suffered at least 111 assaults from other patients and was …

psychiatrygeneral medicinesystemdelaylithium
NSWcommunity2014-07-18

Inquest into the death of Trevor John FOSTER

48y · Male·Incised wounds to the neck

Trevor Foster, a 48-year-old man with severe mental illness (bipolar disorder and schizophrenia), died from incised wounds to his neck. In late 2011, after ceasing p…

psychiatrycannabis
SAhospital2005-04-07

Coroner's Finding: HARRIS Margret Lillian

48y · Female·Chronic Obstructive Airway Disease

…cal care. Clinical lessons include the challenges of managing patients with concurrent severe psychiatric illness and chronic medical disease who lack insight into their conditions, and the importance of palliative care…

psychiatryrespiratory medicinediuretics
NSWcommunity2014-05-01

Inquest into the death of Elijah HOLCOMBE

24y · Male·Gunshot wound to the chest inflicted by Senior Constable Rich of New South Wales…

…g was overly hasty and that Rich lacked adequate justification for the initial chase. The case highlights critical failures in mental health training for police and insufficient de-escalation of a mentally ill person in …

psychiatryemergency medicinecommunicationsystem
TAShome2023-04-03

Coroner's Finding: De-identified HJ

71y · Female·starvation

A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check and fo…

psychiatrygeneral practicecommunicationsystem
SAhome2000-09-15

Coroner's Finding: DONAGHEY Luke Francis

26y · Male·.357 magnum gunshot wounds to the chest and abdomen

Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general pra…

general practicepsychiatrydiagnosticcommunicationhaloperidol
WAhospital2024-09-24

Inquest into the death of Raymond Sydney CHEEK

89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…

… multiple comorbidities including insulin-dependent diabetes, died from complications of gastrointestinal illness with acute renal failure. While medical care at Casuarina Prison was generally appropriate, there was one…

emergency medicineendocrinologymedicationsystemryzodeg insulin
SAaged care2008-06-06

Coroner's Finding: MANN Richard Lesley

45y · Male·choking on food

Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical f…

psychiatrygeneral practicemedicationcommunicationhaloperidol
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