Coronial

9 results for emotional instability

SA2014-08-13

Coroner's Finding: O'DONOHOE Troy

32y · Male·Self-inflicted gunshot wound to head

…0 should have triggered careful reassessment given his documented alcohol-related behaviour and apparent emotional instability. The key clinical lesson is that drink-driving offences, particularly those with significant…

system
WAhome2021-12-15

Inquest into the Death of Child J (Name Subject to Suppression Order)

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

…th highlights systemic issues in remote out-of-home care: staff attrition, resource scarcity, placement instability, and the profound effects of early trauma and FASD on emotional regulation and impulse control. Prevent…

psychiatrypaediatricssystemdelay
TAShome2019-04-24

Coroner's Finding: Porteous, Shayne Edward

59y · Male·mixed drug toxicity (tramadol and sertraline), likely serotonin syndrome

…ately 500mg daily), exceeding safe guidelines. When his sertraline was increased from 100mg to 150mg for emotional instability—symptoms potentially representing early serotonin toxicity—the combined high-dose serotonerg…

general practicepharmacymedicationcommunicationtramadol
VIChome2017-03-09

Finding into death of Patricia Margaret Busby

41y · Female·Gunshot wound to the head

… opportunities, noting that while risk factors for intimate partner violence were present (relationship instability, problematic alcohol use, prior family violence allegations), Murray's actions were unforeseen with no …

WAhome2013

Inquest into the Death of Hurley-Goodacre, Adam Michael

17y · Male·Ligature Compression of the Neck (Hanging) - Suicide

…e week before his 18th birthday. He had a history of suicide attempts in October 2006 while experiencing emotional instability related to relationship difficulties with his girlfriend Rhiannon. Despite involvement of mu…

paediatricspsychiatrysystemalcohol
VIChome2021-04-13

Finding into death of Jason Leslie Smith

44y · Male·Gunshot wound to the head

Jason Smith, 44, was shot in the head by his uncle John Pozzebon in a family violence incident. The coroner found that while Pozzebon had a valid firearms license, his mental health had deteriorated significantly followi…

general practiceforensic medicinecommunicationsystem
VIChome2025-02-07

Finding into death of T

15y · Male·Combined heroin and methamphetamine toxicity

…combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), early trauma, parental substance use history, and escalating mental …

paediatricspsychiatrycommunicationsystemheroin
NSW2022-12-15

Inquest into the death of YAKAMURRO - Findings

15y · Male·Neck compression due to hanging

Yakamurro, a 15-year-old First Nations boy in Territory Families care, died by hanging in NSW in December 2018. The coroner found multiple systemic failures contributed to his death. Key failures: inadequate family consu…

systemcommunication
VIC2024-06-19

Finding into death of X Y

17y · Female·Neck compression by hanging (suicide)

…ent mental health supports (not culturally safe), inadequate support for carers, and repeated placement instability. The coroner identified systemic issues including underfunding of Aboriginal-led services, insufficient…

paediatricspsychiatrycommunicationsystemvenlafaxine

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