Coroner's Finding: DB
28y · Male·ligature strangulation
DB, a 28-year-old with first episode psychosis, was admitted to Nepean Hospital on 31 March 2009 after self-harming. He was appropriately diagnosed and…
99 results for “early psychosis”
28y · Male·ligature strangulation
DB, a 28-year-old with first episode psychosis, was admitted to Nepean Hospital on 31 March 2009 after self-harming. He was appropriately diagnosed and…
16y · Male·Multiple injuries as a result of high speed impact (train)
…en he jumped in front of a train. He was receiving comprehensive mental health care from Southern Health's Early Psychosis Service and was on appropriate antipsychotic medication (intramuscular Resperidone depot injecti…
19y · Male·Multiple injuries sustained on a train impact (pedestrian)
…e misuse involving methamphetamine, cannabis, cocaine, and alcohol. He was enrolled in the Headspace Youth Early Psychosis Program and was receiving treatment with antipsychotic medication (aripiprazole depot). Key clin…
24y · Male·multiple stab wounds to the chest that he inflicted upon himself
…he chest. Clinical lessons include the critical importance of medication adherence in psychotic disorders, early intervention when psychiatric symptoms re-emerge or medication is discontinued, and close liaison between …
45y · Male·Gunshot wounds to the head and left shoulder
…ude: importance of monitoring medication adherence in community-based antipsychotic treatment, recognising early relapse signs (behaviour change, sleep/hygiene disruption), and the critical role of family communication …
69y · Male·Blunt head trauma
…detention. The Coroner found no criticism of the hospital assessment. The critical clinical lesson is that early recognition of deteriorating mental health in the community—particularly signs of command hallucinations a…
32y · Male·multiple injuries caused by a single vehicle crash
A 32-year-old man with long-standing methamphetamine addiction and drug-induced psychosis died in a motor vehicle crash on 6 January 2024. Although he received hospital treatment for severe psyc…
59y · Female·head injury
…ailable supports; and (5) the challenge of maintaining engagement with voluntary patients post-CCO expiry. Early proactive intervention at signs of substance re-use and deteriorating presentation, potentially including …
23y · Male·cerebral hypoxia secondary to strangulation from hanging by belt
…bley, aged 23, was involuntarily admitted to the Mental Health Unit on 19 May 2009 with cannabis-induced psychosis and suicidal ideation. He was placed in the Low Dependence Unit (LDU) based on risk assessment. Nursing …
32y · Female·Blunt force trauma to the head
…te with regular contact, risk assessments, and medication encouragement. Although Mr Ellard displayed some early warning signs of deterioration in the two weeks prior and had substance use issues, minimal typical early …
35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…
…was arrested by police and developed cardiac arrest while in prone restraint. Autopsy revealed significant early-onset atherosclerotic heart disease. The coroner found the police use of force was reasonable and proporti…
21y · Male·multiple injuries from fall from water tower
A 21-year-old man with acute psychosis was admitted involuntarily to a psychiatric ward after being found climbing a power pole. After 8 days, …
58y · Male·coronary artery arteriosclerosis (natural causes)
…iour but was discharged; his presentation was judged appropriate at the time despite later appearing to be early relapse. He re-presented on 22 April 2020 with florid psychosis and was admitted to BMHU under a Form 6A i…
39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…
…utcomes would require immediate recognition as medical emergency, rapid restraint with adequate personnel, early medical involvement, and transport to hospital rather than prolonged field management.
37y · Female·open finding - undetermined
…ckling-Bryen disappeared on 19 February 2016 and is presumed dead. She had a history of schizophreniform psychosis with a 2013 hospitalisation during which she expressed suicidal ideation. Post-discharge, she received i…
23y · Male·Unable to be determined from available evidence
…mpliant, ceasing medications due to perceived side effects. His mental state deteriorated significantly in early March 2004, with intensifying paranoia and behavioural changes. He was last seen leaving his mother's home…
19y · Female·The available evidence does not allow for a finding as to the cause of death
…depression after a relationship ended. Medical staff documented her as a real suicide risk with signs of psychosis and possible severe personality disorder. Despite her family's extensive search and modern investigative…
45y · Male·coronary artery disease and mechanical asphyxia in a man using cocaine
A 45-year-old man with a history of drug-induced psychosis, cocaine use, and underlying coronary artery disease died in police custody following physical restraint…
28y · Male·hanging
Aaron Nathan Stagg, 28-year-old man with likely Asperger's Syndrome and emerging paranoid psychosis, died by hanging on 5 March 2010 after a period of disengagement from mental health services. He was ref…
36y · Male·Hypoxic ischaemic encephalopathy due to cardiac arrest occurring during restrain…
… showing concerning behavioral changes in the weeks prior. Critical clinical lessons include: the need for early recognition of acute psychiatric symptoms and drug-induced psychosis; the importance of mental health asse…
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