Coronial
NSWhome2017-03-07

Inquest into the death of Louis NAUMOVSKI

59y · Male·Unascertained

…luded intentional or unintentional opioid overdose, or cardiac/respiratory complications. He had chronic dysthymia, social isolation, and poor engagement with addiction and mental health services. Clinical lessons inclu…

addiction medicinepain medicinefentanyl
SAhome2020-12-07

Coroner's Finding: ROBERTS Paul Scott

38y · Male·combined effects of inhalation of products of combustion and incineration

… himself alight during police attendance at his home on home detention bail. He had a history of chronic dysthymia, alcohol abuse, and previous self-harm threats. Roberts made repeated calls to his ex-partner threatenin…

communicationalcohol
SAcommunity2012-06-18

Coroner's Finding: JORKOWSKI Natassja Alexandra

19y · Female·asphyxiation

A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…

psychiatrygeneral practicediagnosticcommunicationescitalopram
WAmental health2024-04-08

Inquest into the Death of Paul McLOUGHLIN

59y · Male·incised injuries to the neck

Paul McLoughlin, a 59-year-old man with long-standing bipolar affective disorder, schizoaffective disorder, and heavy cannabis use, died by suicide via incised neck wounds while on day leave from Graylands Hospital. He w…

psychiatryvenlafaxine
SAhospital2016-05-19

Coroner's Finding: WILLIAMS Jeremy Todd and CAMPBELL Robert

Male·neck compression due to hanging

…my Williams (24) was comprehensively assessed by a mental health nurse but received a wrong diagnosis of dysthymia (rather than major depression) from a non-psychiatrist, devastating his confidence in getting help. Neit…

emergency medicinepsychiatrydiagnosticcommunicationcitalopram
SAhome2007-03-30

Coroner's Finding: LYND Darrell James

37y · Male·hypoxic ischaemic encephalopathy secondary to hanging

A 37-year-old man with depression, suicidal ideation, and antisocial personality disorder died from hypoxic ischaemic encephalopathy following hanging while on home detention bail. He had been arrested following a domest…

psychiatryemergency medicineantidepressant medication
VICcommunity2013-01-31

Finding into death of Stuart Beverley

31y · Male·Hanging

A 31-year-old man with borderline personality disorder presented to mental health services after a suicide attempt on 30 March 2005, discharged after psychiatric assessment at Maroondah Hospital ED. Following several cri…

psychiatryemergency medicinecommunicationdelaydiazepam
NSWmental health2020-11-27

Inquest into the death of JP

46y · Female·hypoxic brain injury due to hanging

A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…

psychiatryemergency medicinecommunicationprocedural
QLD2023-09-19

AJO - findings

34y · Male·Hanging

A 34-year-old remand prisoner died by hanging in his cell at Arthur Gorrie Correctional Centre. He had a history of child sexual offences and mental health issues including depression and past self-harm. Initial risk ass…

psychiatrycorrectional healthcannabis
VICcommunity2016-08-09

Finding into death of Nicolas Russell Miles

22y · Male·Head and neck injuries sustained in a train incident

Nicolas Russell Miles, aged 22, died from head and neck injuries after deliberately lying on railway tracks in front of a moving train on 12 January 2015. He had a history of anxiety, psychosis, and attention deficit dis…

general practicepsychologyescitalopram
VIChospital2013-09-17

Finding into death of Richard Hilton

27y · Male·Hanging

Richard Hilton, a 27-year-old with longstanding bipolar affective disorder and benzodiazepine dependence, presented to Werribee ED three times in two months with suicidal ideation and self-harm attempts. Each time he was…

psychiatryemergency medicinediagnosticcommunicationalprazolam
VIChospital2024-12-02

Finding into death of S K

25y · Male·Gunshot injury to the head

SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…

emergency medicinepsychiatrysystemdelaymethamphetamine
VICcommunity2017-07-07

Finding into death of SO

27y · Male·Mixed drug toxicity

A 27-year-old man with polysubstance abuse disorder, generalised anxiety disorder, and borderline personality disorder died from mixed drug toxicity (heroin, morphine, diazepam, citalopram, quetiapine) shortly after disc…

psychiatryaddiction medicinedischargesystemheroin
NSWhospital2018-04-27

Inquest into the death of Matthew Wilson Leary

25y · Male·drowning

Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …

psychiatryemergency medicinediagnosticcommunicationcitalopram
WAmental health2000-08-18

Inquest into the Death of Wendy Anne Eadie

29y · Female·asphyxiation due to ligature compression of the neck (hanging)

Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…

psychiatryforensic medicinecommunicationsystemparoxetine
WAhospital2012-05-31

Inquest into the Death of GARRETT

52y · Male·HIV infection complicated by basal and squamous cell carcinoma of the head and n…

Bruce Jason Garrett, a 52-year-old prisoner detained under the Dangerous Sexual Offenders Act, died at Royal Perth Hospital on 2 October 2010 from HIV infection complicated by basal and squamous cell carcinoma of the hea…

emergency medicineintensive careheparin
QLDmental health2007-06-20

Eady, Graeme William Julian

25y · Male·hypoxic-ischaemic brain injury due to plastic bag asphyxia

Graeme Eady, 25 years old with chronic depression first formally treated in July 2003, was admitted after a suicide attempt in September 2003. Following an altercation with another patient, he was transferred to H Floor …

psychiatryemergency medicinesystemproceduralsertraline
VIChome2024-08-29

Finding into death of A S

19y · Female·sodium nitrite toxicity

This finding concerns the death of a 19-year-old transgender woman (referred to as 'AS') who died from sodium nitrite toxicity on 9 May 2021. She ingested sodium nitrite during a video call with a friend in NSW. AS had a…

psychiatryendocrinologysystemsodium nitrite
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

24y · Male·0.22 calibre gunshot wound to the head (self-inflicted)

Christopher Merritt, a 24-year-old man with a history of reactive depression triggered by relationship breakdowns, presented to his GP Dr W. on 30 June 2003 with acute tearfulness, suicidal ideation, and dangerous reckle…

general practiceemergency medicinediagnosticcommunicationcitalopram
SA2003-12-18

Coroner's Finding: LINDSAY Margaret

38y · Female·neck compression due to hanging

Margaret Lindsay, 38, died by hanging in Adelaide Women's Prison on 23 May 2001 whilst remanded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite…

psychiatrycorrectional healthcommunicationsystemdiazepam

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