Coronial

568 results for mental health intervention

VIChome2025-11-04

Finding into death of Kon Maximos

62y · Male·Shotgun injury to the head

…cute interpersonal crisis following marital separation, family estrangement over infidelity, and police intervention for family violence. Critical clinical and systemic failures included: inadequate mental health assessm…

psychiatrypsychologydiagnosticcommunicationmirtazapine
NSW2024-10-31

Inquest into the death of AB

34y · Male·Incision/stab wound to the neck

…ck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 days earlier, despite recommendations for two-occupant…

psychiatryemergency medicinediagnosticsystem
VIChome2025-01-31

Finding into death of Nicky Kudrin

60y · Male·Gunshot wound to the head (self-inflicted)

… found Victoria Police response timely and appropriate per policy. Contributing factors included untreated mental health symptoms following marital breakdown, alcohol and methamphetamine use, unserved family violence int…

methamphetamine
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was…

psychiatryemergency medicinecommunicationsystemdiazepam
VIChome2019-10-07

Finding into death of Tre Leigh Lawson

21y · Male·Hanging

…d by hanging following a tumultuous relationship involving family violence, substance abuse, and unmanaged mental health issues. He had attempted self-harm in May 2017 and was assessed as low imminent risk but never enga…

psychiatryemergency medicinecommunicationsystemmethamphetamine
SAhome2019-07-24

Coroner's Finding: McNAMARA-CUTLER Juanita Lee

26y · Female·neck compression due to hanging

Juanita Lee McNamara-Cutler, a 26-year-old mother of three with a complex history of mental illness, substance abuse, and prior suicide attempts, died by hanging on 7 September 2014, three days afte…

psychiatryforensic medicinemethamphetamine
QLDcommunity2015-12-14

Young, Anthony William; Young, David Kenneth Baring; Dekens, Louise Alexandra

42y · Male·Anthony Young: multiple gunshot wounds to the body and arm; David Young: multipl…

…t by police after fatally stabbing his brother David and David's partner Louise. Anthony had deteriorating mental health including paranoia, substance use, and lack of psychiatric engagement despite family attempts to ob…

psychiatryforensic medicinediazepam
NTcommunity2016-03-09

Inquest into the death of Ronald Donaldson

69y · Male·Blunt head trauma

…with unusual presentation but experienced clinicians appropriately determined he did not meet criteria for mental illness detention. The Coroner found no criticism of the hospital assessment. The critical clinical lesson…

psychiatryemergency medicinedelaymarijuana
NSW2017-07-11

Inquest into the death of LP

72y · Male·multiple injuries resulting from catastrophic head injury with massive disruptio…

…ven the patient's clear determination and short timeframe, but the case highlights risks of third-party intervention in active suicide negotiations and the importance of trained negotiators in mental health crises.

psychiatrycorrectional health
VIChome2018-12-07

Finding into death of Wayne Brown

38y · Male·Stab wound to the chest

…ad a documented history of perpetrating family violence, including multiple breaches of Family Violence Intervention Orders, threats, and assaults against family members. He presented with significant risk factors includ…

alcohol
VIC2021

Finding into death of Thi Minh Phuong Nguyen

29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…

…r violence died from mixed drug toxicity (GHB, methylamphetamine, amphetamine, diazepam). She had multiple mental health diagnoses including PTSD, depression, bipolar disorder, and postnatal depression. Her son was remov…

general practicepsychiatrycommunicationsystemgamma hydroxybutyrate
WAcommunity2021-05-11

Inquest into the Death of Janice Ann CROFT

64y · Female·phosphine toxicity from deliberate ingestion of aluminium phosphide fumigation p…

…Croft, 64, died from phosphine toxicity after deliberately ingesting fumigation pellets during a police intervention on her property facing eviction for mortgage default. Ms Croft had long-standing bipolar disorder and w…

emergency medicinetoxicologysystemlithium
SAhome2000-09-15

Coroner's Finding: DONAGHEY Luke Francis

26y · Male·.357 magnum gunshot wounds to the chest and abdomen

…g his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental health services despite clear evidence of florid psychosis. The GP refused detention under the Mental Heal…

general practicepsychiatrydiagnosticcommunicationhaloperidol
VICcommunity2011-05-16

Finding into death of Aaron

14y · Male·injuries sustained in fall from height

…ance misuse, poor school attendance, and homelessness. The coroner found that DHS failed to conduct proper mental health assessments despite documented self-harming behaviour and suicidal ideation expressed to friends. M…

paediatricspsychiatrydiagnosticsystem
VIChome2014-10-06

Finding into death of Peter Andrew McNay

50y · Male·hanging

…ar-old male with long-standing substance abuse history (alcohol, marijuana, heroin until 2009) and complex mental health issues including depression, anxiety, personality traits, and multiple prior suicide attempts. Foll…

psychiatryaddiction medicinealcohol
TAScommunity2016-09-30

Coroner's Finding: Westbrook, Eden Jayde

15y · Female·asphyxia due to hanging

…hough Eden experienced some distress there and online. Eden's death highlights the critical need for early mental health intervention in adolescents, particularly when family recognizes warning signs including explicit s…

psychiatrypaediatricssystemdelay
VIChome2021-08-03

Finding into death of V T

75y · Female·Multiple injuries including stab wounds to the chest

…ed aggression toward his mother, and repeated threats to kill her. Family members and friends observed his mental health deterioration in the weeks prior, including delusional thinking and bizarre behavior. Police had at…

psychiatrygeneral practicecommunicationsystem
QLDPodcast2020-06-30

Ayliffe-Chung, Mia Mishka Annie and; Jackson, Thomas Leslie - Non-inquest findings

Unknown·Mia: Stab wound to heart; Thomas: Stab wound to brain

…recognize or escalate concerning behavioral changes despite witnesses noting 'something was wrong'; (4) no mental health intervention occurred despite clear indicators of mental illness on the day of attack. While Ayad h…

psychiatryemergency medicinesystemcommunicationcannabis
VIC2017-07-31

Finding into death of Ahmad Numan Haider

18y · Male·gunshot wound to the head

…pon-seeking behaviour, and family estrangement. Prevention requires early identification and specialist intervention through mental health and community services networks.

psychiatrygeneral practicecommunicationsystem
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

49y · Male·Multiple injuries sustained when struck by a truck

…) and held briefly at Kempsey Police Station. Critical clinical and systemic failures were identified: the mental health service failed to escalate appropriately after Sandra reported concerning behavioural changes sugge…

psychiatryemergency medicinecommunicationsystemmethamphetamine
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