Coronial
VICmental health2025-05-19

Finding into death of Anna Lee

70y · Female·Asphyxia due to airway obstruction

… due to airway obstruction while an inpatient in a mental health unit. She was admitted with first-episode mania with psychotic features, triggered by financial scam victimization. Despite appropriate psychiatric manage…

psychiatrygeriatric medicinesystemolanzapine
VICaged care2019-10-15

Finding into death of Patricia O'Connor

84y · Female·Multisystem organ failure related to complications from a fall resulting in hip …

…-stimulus area despite being assessed as high falls risk. She underwent surgery on 27 August but her acute mania, severe agitation, and challenging behaviour made post-operative management extremely difficult. Staff cou…

psychiatrygeriatric medicinesystempaliperidone
VICmental health2024-08-09

Finding into death of Con Kostantinou

63y · Male·Unascertained - natural causes. Cardiac arrest with secondary hypoxic-ischaemic …

…d emphysema was admitted involuntarily to Northern Hospital on 24 March 2024 after exhibiting delirium and mania with medication non-compliance. He was assessed as high risk and managed under Mental Health Act orders. D…

psychiatrygeneral medicinediazepam
SAhospital2021-11-23

Coroner's Finding: Barry, Margaret Joan

80y · Female·Right haemothorax due to bleeding right pleural adhesion with contributing apixa…

…n. She was admitted to Royal Adelaide Hospital for psychiatric care under an Inpatient Treatment Order for mania following cessation of carbamazepine. On 24 April 2019, after slipping in the bathroom and experiencing dr…

psychiatrycardiologyapixaban
TASmental health2026-04-13

Coroner's Finding: de-identified DR

41y · Male·asphyxia due to neck compression following ligature suspension (hanging)

…rs including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania and psychosis, requiring compulsory psychiatric hospitalization. After three weeks inpatient treatment, he…

psychiatryemergency medicinediagnosticcommunicationolanzapine
VIChome2010-03-15

Finding into death of Terence Thomas Wilson

76y · Male·Upper airway obstruction by food bolus in a man with ischaemic heart disease

Mr Terence Wilson, aged 76, died from upper airway obstruction by food bolus while attending a family gathering. He had recently been diagnosed with ischaemic heart disease requiring bypass surgery and bipolar affective …

emergency medicinepsychiatrysodium valporate
VICmental health2014-12-23

Finding into death of David John McLeod

58y · Male·Cardiomegaly and severe single vessel coronary artery atherosclerosis in a man w…

David John McLeod, a 58-year-old man with schizoaffective disorder, was admitted to a psychiatric inpatient unit on 21 August 2012 following mental health deterioration. He presented with signs of infection, received app…

psychiatrygeneral medicinerisperidone
TAScommunity2020-11-23

Coroner's Finding: Golding, Laura Rebecca

51y · Female·drowning

Laura Golding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay withou…

psychiatrygeneral practicesystemdelay
QLD2006-04-07

Meech, Paul Andrew

40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…

Paul Meech, a 40-year-old man with bipolar affective disorder, died of asphyxia caused by a seizure from severe alcohol intoxication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The …

psychiatryemergency medicinediagnosticcommunicationhaloperidol
NSWmental health2019-06-04

Inquest into the death of Andrea Sewell

46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…

Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (P…

psychiatryneurologyantipsychotic medications
SAhospital2019-03-08

Coroner's Finding: PETERS Clinton Neal

40y · Male·metastatic malignant melanoma

A 40-year-old man with metastatic melanoma died at Queen Elizabeth Hospital on 2 September 2015. He had atypical nevi removed in 2009 and melanoma diagnosed in 2013, initially undergoing surgery with curative intent. How…

oncologyemergency medicinediagnosticdelay
VIChospital2015-07-09

Finding into death of Male D

52y · Male·Multiple injuries and immersion leading to hypoxic brain injury and pneumonia

Male D, aged 52, died from multiple injuries and immersion leading to hypoxic brain injury and pneumonia sustained during an assault. The perpetrator, Y, was a patient with schizo-affective disorder admitted involuntaril…

psychiatryemergency medicinediagnosticsystemzuclopenthixol decanoate
WAcommunity2017-09-06

Inquest into the Death of James Michael Chee Ming YUNG

42y · Male·Multiple injuries sustained in motor vehicle crash

A 42-year-old man with schizoaffective disorder subject to a Community Treatment Order died in a single-vehicle motor crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern…

psychiatryemergency medicinedelaysystempaliperidone depot
VICmental health2025-07-24

Finding into death of Mr SWX

32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity

A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …

psychiatryemergency medicinemedicationcommunicationolanzapine
VIChospital2020-07-14

Finding into death of Gerard Guy Vaz

61y · Male·Undetermined

Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
SAmental health2020-09-22

Coroner's Finding: NOONAN Ricky Dale

54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking

A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…

psychiatryemergency medicinecommunicationsystemhaloperidol
VICcommunity2022-12-01

Finding into death of Gabriel Messo

30y · Male·Gunshot wounds to the chest

Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mother at John Coutts Reserve. Clinical lessons inclu…

psychiatryemergency medicinecommunicationsystem

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