20y · Female·injuries received from a fall from the viewing platform at Perriwen Lookout at M…
…al ideation. She was admitted to the psychiatric ward with initial diagnosis of adjustment disorder with depressed mood and anxiety. On 20 May 2005, she showed objective clinical improvement: appeared less anxious, deni…
43y · Male·complications of thermal injuries
A 43-year-old man with a history of workplace injury, financial stress, and social isolation attended a workers compensation office in Newcastle carrying mineral turpentine and a cigarette lighter. After about 23 minutes…
22y · Male·Multiple injuries secondary to fall from a height
…oodburn, a 22-year-old with first-episode psychosis presenting with command hallucinations, paranoia and depressed mood, was admitted as a voluntary patient to an unlocked inpatient unit at Orygen Youth Health on 19 Jan…
32y · Male·unascertained; most likely exposure after walking in bushland
…acute psychiatric admission for active suicidality. He was last seen by his partner appearing grumpy and depressed. His locked caravan was found with personal items (wallet, mobile phone, medication) still inside, sugge…
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
…olar I but frequently missed. Critical clinical errors included: general practitioners failing to recognize mood swings as potential bipolar indicators; a psychologist attempting to treat with mindfulness-based technique…
56y · Male·Asphyxia
Stuart Cecil Ford, a 56-year-old prisoner at Wolston Correctional Centre, died by asphyxiation when he intentionally placed a plastic bag over his head on 16 January 2010. He had a history of adjustment disorder with anx…
58y · Male·asphyxiation by ligature
…tification and observation form with no interpreter offered; incomplete mental health assessment despite depressed mood on standardised testing; language barriers not adequately addressed; no family contact permitted fo…
60y · Female·multiple injuries
…ons contemplating jumping, she did not engage with psychiatric follow-up after discharge in April 2023. Her mood declined in the weeks before death, she resigned from work citing distress, and she visited Redhead Headlan…
29y · Male·Hanging
… who did not report it; (3) absence of mental health screening or intervention despite clear indicators (depressed mood, previous self-harm attempt in 2014, notebook entries with persecutory ideation); (4) barriers to h…
30y · Male·hanging
…e episodes of self-harm. Despite appropriate psychiatric assessment and medication trials (antidepressants, mood stabilisers), he was discharged from the infirmary to general protective custody on a yellow sheet suicide …
58y · Male·gunshot wounds
Senior Sergeant Michael James Isles, a 58-year-old Queensland police officer with 34 years of service, disappeared on 23 September 2009. He was the subject of corruption allegations (which proved unfounded), stood down f…
46y · Male·Hanging (suicide)
…dical circumstances contributing to his death. Key clinical observations include evidence that he became depressed in the months before death, with changing eating habits, job loss, and social withdrawal. He had limited…
46y · Male·unknown
This inquest concerns Paul Rushworth, a 46-year-old man reported missing on 13 September 2013 after leaving home for a walk. Paul had a history of depression and anxiety treated in 2010-2011, and had experienced increasi…
34y · Female·Neck compression from ligature strangulation
This dual inquest examined deaths in Smithfield on 4 September 2016. A male partner (48) killed a female partner (34) while their three-year-old daughter was present. Separated but cohabiting, the couple's breakdown acce…
51y · Male·neck compression due to hanging
A 51-year-old man on remand in prison died by hanging in his cell. He had a psychiatric history including depression and a family history of suicide, but showed no signs of self-harm risk during nine months of incarcerat…
17y · Male·ligature compression of the neck (hanging)
…erdosing on his ADHD medication (Strattera). He had recently ceased this medication and was experiencing depressed mood and anxiety. He was assessed by a psychiatrist (Dr H.) on 25 November 2010 who deemed him at low-to…
51y · Male·Injuries sustained in a train incident
… in mental health patients and the need for vigilant identification of warning signs such as anxiety and depressed mood.
38y · Female·Multiple injuries sustained when struck by a train
…nt is distressed and unsupported; emergency departments should conduct proper psychiatric assessment for depressed patients; workplace mental health support must be proactive and credible.
19y · Male·Hanging
Kyle Horne, a 19-year-old with high-functioning autism, died by hanging on 15 March 2018 following relationship breakdown. He presented to his GP on 8 March 2018 requesting a Mental Health Care Plan, citing relationship …
36y · Male·Global hypoxic brain injury due to hanging
Benjamin Johnston, a 36-year-old male, died by hanging after six weeks of varenicline (Champix) treatment for smoking cessation. Two weeks before death, his partner noted significant behavioral changes: withdrawal, irrit…
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