Coronial

87 results for mental ill-health

WAhospital2026-04-01

Inquest into the Death of David John HATCHER

60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…

…are. Despite comprehensive care from multiple specialist teams (Respiratory Medicine, Infectious Diseases, Mental Health), he could not overcome his terminal illness. Key factors in his death included TB on a background …

respiratory medicineinfectious diseasesproceduralsystem
VIC2026-03-05

Finding into death of Darryn Leslie Beaton

22y · Male·Unascertained

…survival. The coroner concluded he is deceased but the exact cause remains unascertained, likely involving mental health decompensation, becoming lost in bushland, and death from exposure or possible suicide. This case h…

psychiatry
NSWcommunity2014-05-01

Inquest into the death of Elijah HOLCOMBE

24y · Male·Gunshot wound to the chest inflicted by Senior Constable Rich of New South Wales…

… from a gunshot wound inflicted by Senior Constable Rich during a police encounter in Armidale. Elijah had mental health issues and was being assessed at hospital when he left voluntarily before full psychiatric evaluati…

psychiatryemergency medicinecommunicationsystem
NSW2019-07-04

Inquest into the death of RP and DJ

Male·RP: fatal pressure to the neck; DJ: neck compression

…inmates died in separate incidents at the Metropolitan Remand and Reception Centre after being placed with mentally ill cellmates exhibiting acute psychosis. RP died in 2010 from injuries inflicted by cellmate MA, who wa…

psychiatrydiagnosticcommunicationquetiapine
VIChome2020-11-06

Finding into death of Robert Thomas Love

33y · Male·Undetermined

Robert Thomas Love, a 33-year-old man with a history of alcohol and drug abuse and mental health difficulties, was found dead in his home in February 2015. The cause of death remains undetermined.…

addiction medicinegeneral practicebaclofen
TAShome2023-04-03

Coroner's Finding: De-identified HJ

71y · Female·starvation

A 71-year-old woman with chronic mental illness died of starvation in her home in Tasmania. Police attended on 9 December 2021 for a welfare check…

psychiatrygeneral practicecommunicationsystem
QLD2006-04-07

Meech, Paul Andrew

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

…ication while in police custody at Hervey Bay watch house. Critical failures occurred: (1) The Maryborough Mental Health Unit discharged him twice in late July 2003 despite clear manic symptoms and documented history, ci…

psychiatryemergency medicinediagnosticcommunicationhaloperidol
VIChome2023-05-29

Finding into death of Stuart John Noble

47y · Male·Multidrug toxicity (ethanol, quetiapine, baclofen, benzodiazepines)

…sk in patients with alcohol use disorder. Stuart had multiple risk factors including long-term alcoholism, mental ill-health, prior suicide attempt, and recent relationship breakdown with family violence. The coroner hig…

general practiceaddiction medicinediagnosticsystembaclofen
NSW2024-12-03

Inquest into the death of Simon Cartwright

41y · Male·Septicaemia secondary to chronic peptic ulcer disease

… at MRRC from August 2021, his medical history was not reviewed on intake. Although he was identified as a mentally ill person on 3 September 2021 and ordered transferred to Long Bay Forensic Hospital, no bed became avai…

psychiatrygastroenterologydiagnosticsystempantoprazole
NSWhospital2011-03-04

Williammackenzie 2011 03 04 12 58 08 816

60y · Male·Multiple injuries sustained after jumping from 15th storey home unit

… on 9 June 2008 with suicidal ideation after being found lying in traffic. Dr W. correctly assessed him as mentally ill and placed him on involuntary status. However, approximately five hours later, after sedating medica…

psychiatryemergency medicinediagnosticproceduralolanzapine
VIChome2014-03-06

Finding into death of Kylie Jane Fowler

36y · Female·Effects of Fire

…y rejected treatment, had poor medication compliance, and was never engaged with a GP after discharge from mental health services in September 2007. Critical gaps included: no confirmation of GP engagement post-discharge…

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2014-03-06

Finding into death of Matthew Patrick James Maher

36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …

…uary 2011 in a house fire following stab wounds to two children. She was discharged from Darebin Community Mental Health Service in September 2007 to GP care but never engaged with a general practitioner thereafter. The …

psychiatrypaediatricscommunicationsystemrisperidone
VIC2022-11-23

Finding into death of Gerald Van Der Werf

56y · Male·Consistent with hanging

…confirmed identity. The coroner made definitive findings that Van Der Werf died by hanging, with declining mental health and history of suicidal ideation contributing to his death. This case highlights the importance of …

forensic medicine
VICcommunity2025-11-11

Finding into death of Veronica Norah Cheney

43y · Female·undetermined

…ce of life. The coroner concluded she died on or after 1 March 1945 from an undetermined cause, noting her mental health history and prior disappearance. This case highlights gaps in historical police record management a…

psychiatrypathology
SAhospital2017-04-19

Coroner's Finding: FIRTH Angela Beryl

63y · Female·metastatic adenocarcinoma of the lung

…elaide Hospital. She presented with behavioural disturbance secondary to brain metastases, was assessed by mental health services, and lawfully detained under the Mental Health Act 2009. She deteriorated on 22 November 2…

oncologypsychiatry
VICcommunity2019-04-29

Finding into death of William Willms

63y · Male·Unknown

William Willms disappeared on 23 July 1973 at age 63 after boarding a bus to Lilydale railway station. He had recently self-discharged from psychiatric admission for endogenous depression and suicidal ideation. Despite e…

psychiatrygeneral practicesystemdelay
NSWhospital2015-07-02

Inquest into the death of N

69y · Female·Asphyxiation consistent with hanging

…woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While individual investi…

neurologypsychiatrydiagnosticcommunicationphenytoin
NThospital2010-08-11

Inquest into the death of Gottlieb Rubuntja

39y · Male·coronary atherosclerosis

…gitated behaviour. His mother and family had requested police assistance; he appeared to be experiencing a mental health crisis with hallucinations and disorganized speech. Police determined apprehension was necessary un…

emergency medicineforensic medicineproceduralcommunication
NSWhospital2023-07-21

Inquest into the death of Ziad Hamawy

51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …

…e disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019. He had been involuntarily admitted under a court order and was assessed by t…

psychiatryemergency medicinediagnosticcommunicationheroin
VICcommunity2025-04-14

Finding into death of Jodus Tenetahi Murphy

18y · Male·Unascertained; likely hypothermia possibly in combination with drowning

… significant life disruption following his grandparents' relocation to New Zealand and had disengaged from mental health support. On 14-15 May, he consumed methylamphetamine, bromazolam, and cannabis at an acquaintance's…

forensic medicinetoxicologymethamphetamine

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