Coronial

26 results for impulsive self-harm behaviour

SAhome2014-11-28

Coroner's Finding: DAVIDSON Ian John

60y · Male·stab wound of chest (self-inflicted)

… days earlier, psychiatric assessment at Royal Adelaide Hospital found no acute psychiatric diagnosis or self-harm risk. A consultant psychiatrist's earlier report noted recurrent depressive disorder with dependent pers…

psychiatryemergency medicine
SAhospital2006-06-22

Coroner's Finding: MERRITT Christopher Simon

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

…mmary documenting Temazepam overdose with psychiatric assessment, which would have revealed a pattern of impulsive self-harm. Dr W.'s assessment failed to appreciate the seriousness of this presentation or escalate appr…

general practiceemergency medicinediagnosticcommunicationcitalopram
VIC2011-02-17

Finding into death of Sean Wayne Lee

20y · Male·Head injury

…te no obvious warning signs observed by police. Clinical lessons include recognizing that suicide can be impulsive despite future planning, and that anxiety-depression in younger people requires proactive engagement wit…

neurosurgerytrauma surgery
WAcommunity2025-10-24

Inquest into the Suspected Death of Guido MICHEL

54y · Male·unascertained cause

…om unascertained cause, with open manner finding. Clinical lessons: mental health patients with previous self-harm, those experiencing multiple concurrent stressors, and those ceasing engagement with regular psychologic…

psychiatrygeneral practicesystemcommunicationdextroamphetamine
VIC2022-03-08

Finding into death of Dylan James Charlton-Smith

25y · Male·Hypoxic ischaemic brain injury due to hanging

…responses rather than health-based interventions. Mental health assessment did not occur despite his S4 (self-harm history) rating. While staff made vigorous resuscitation efforts, the coroner found the decision to addr…

psychiatryemergency medicinediagnosticcommunication
VICcommunity2011-03-25

Finding into death of Gerard Patrick O'Brien

34y · Male·Injuries sustained in a fall from a height

…gate Bridge following a brief police pursuit. The coroner found he intentionally took his own life while impulsively attempting to avoid police interception. O'Brien had been drinking, driving with a cancelled licence, …

VICmental health2014-01-23

Finding into death of Kate Tamma Miller

39y · Female·hanging

…he had severe borderline personality disorder with recurrent high-lethality suicide attempts and chronic self-harm urges. A shared care arrangement between TMC and Alfred Hospital provided coordinated treatment includin…

psychiatryintensive caresystemdiazepam
VIChospital2022-10-10

Finding into death of Oliver Vincent Paul Cronin

13y · Male·Hanging

…d boy, died by hanging at Royal Children's Hospital after a year-long escalation of gaming addiction and behavioural problems. He had become increasingly dependent on gaming platforms (Roblox, Minecraft, Clash of Clans,…

psychiatrypsychologydiagnosticsystem
SA2024-12-20

Coroner's Finding: Huddy, Kobee Michael David

20y · Male·gunshot wound to the chest

A 20-year-old man with borderline personality disorder, who had made over 25 suicide attempts in the two years prior, died from a gunshot wound sustained during a police encounter. He had called mental health services an…

psychiatryemergency medicinecommunicationsystemcannabis
WAhome2002-07-05

Inquest into the Death of Bradley William Rapley

22y · Male·Hypoxic Ischaemic Encephalopathy due to suffocation

…ina Prison cell on 25 August 1999. Rapley was a prisoner with a history of depression, anxiety, and past self-harm attempts, though he was inconsistent in reporting these to authorities. He was returned to Casuarina Pri…

psychiatrygeneral practicesystemcommunicationdosulepin
NSWmental health2014-06-18

Inquest into the death of Mark Richard GLEESON

39y · Male·respiratory failure as a result of the interaction of prescribed medication and …

…Mental Health Unit on 21 December 2011. He had been admitted voluntarily with command hallucinations and self-harm thoughts but was deemed competent to refuse proposed treatment and discharged at his insistence. He was …

psychiatryolanzapine
QLDcommunity2024-10-11

Findings of the inquest into the death of Luke Brian Gilbert

24y · Male·Gunshot wounds to the chest

…ad documented alcohol use disorder, antisocial personality disorder, and previous suicidal ideation with self-harm scarring. He presented to hospital with suicidal ideation 9 days before death but disengaged after crisi…

emergency medicinepsychiatryalcohol
WAhome2007-12-03

Inquest into the Death of Tedeschi

14y · Female·Ligature compression of the neck (suicide)

Gabrielle Mia Tedeschi, a 14-year-old girl with longstanding oppositional and self-harm behaviours and subsequent depression, died by suicide on 14 October 2004 following a ligature compressio…

psychiatrypsychologycommunicationdelayfluoxetine
NSWhome2024-06-12

Inquest into the death of Douglas Thrift

71y · Male·strychnine toxicity

Douglas Thrift, 71, died from strychnine toxicity on 1 December 2018 at his home in Denman NSW. He had a long history of depression and alcohol use disorder with two prior suicide attempts (1984, 2009). On the day of his…

strychnine
WAhome2014-10-17

Inquest into the Death of Ethan (Subject to a Suppression Order)

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

A 15-year-old Aboriginal boy in foster care died by suicide following apparent impulsive response to adolescent boundary conflicts. Despite stable, loving foster placement since age 4, Ethan re…

psychiatrypsychologymelatonin
NSWcommunity2022-10-07

Inquest into the death of Charli Powell

17y · Female·Hanging

…ely communicated between NSW and ACT jurisdictions. The coroner noted an untreated mood disturbance with self-harm history, cannabis use, recent miscarriage, and youth justice breaches contributed to her despair. The pa…

pathologypsychiatrysystemcommunicationcannabis
SA2011-06-08

Coroner's Finding: MORRIS Julia Hisae and JAST Raymond Glen

Unknown·Gunshot wound to the head (self-inflicted)

…ing marital and financial crisis, also accessed firearms readily despite an instructor noting concerning behaviour. The coroner identified that neither individual held firearms licenses or club memberships, making them …

psychiatryemergency medicinesystemcommunication
WAhome2005-12

Inquest into the Death of Jake Willem Dunne-Heynis

15y · Male·Ligature Compression of the Neck (Hanging)

…g himself at home. Jake had motor coordination difficulties attributed to poor eyesight, and experienced behavioural outbursts and educational struggles. A central conflict emerged between Jake's reluctance to continue …

communicationsystem
VIChome2019-01-08

Finding into death of Fiona Kellie Burke

32y · Female·hanging

Fiona Burke, aged 32, died by hanging on 17 March 2017 following a prolonged history of family violence in her relationship with Darren Mather. The death occurred in a context of escalating intimate partner violence, alc…

paediatricspsychiatrycommunicationsystemalcohol
TAShospital2019-09-26

Coroner's Finding: Peck, Edward Paisley

23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…

A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts w…

psychiatryemergency medicinecommunicationdiagnosticlithium carbonate

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