31y · Female·neck compression in the circumstances of hanging
Tessa Ballam, a 31-year-old accountant with longstanding depression, anxiety, bulimia nervosa, and borderline personality disorder (BPD), died by hanging in August 2015. She had expe…
45y · Male·Hanging
…November 2015. In May 2017, he presented with low mood, refusing antidepressants initially. Following a performance management process at work in July 2017—triggered by concerns about his motivation and performance—he b…
39y · Male·Compression of the neck consequent upon hanging
Adrian Young, a 39-year-old voluntary inpatient with severe treatment-resistant depression and chronic anxiety, died by hanging while on day leave from the Melbourne Clinic. He had been under psychiatric care since 2…
46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)
…o policy, the manner and timing of investigations into trivial matters, combined with implied threat of performance management processes and unclear employment status, created cumulative stressors he could not manage. H…
58y · Male·Hanging
… scheduled 7 weeks later on 17 May 2019. The coroner found this wait time did not meet Justice Health's performance standard of 30 days for non-urgent psychiatric referrals. Although the coroner accepted that timely psy…
62y · Male·Self-inflicted intentional hanging
…han asylum seeker, died by hanging in an immigration detention centre on 15 June 2013. He had experienced anxiety, depression and PTSD during detention and was under psychological care. Although he never explicitly expr…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
… He had complex medical needs including chronic back pain, spinal fusion, post-viral fatigue, depression, anxiety, and gender dysphoria. Critical clinical lessons include: (1) recognition that suicide can be impulsive w…
24y · Male·Combined drug toxicity (morphine and diazepam)
…aining large quantities of medications while concealing his attendance at multiple providers. Depression, anxiety, and prescription drug addiction progressively deteriorated his mental health, work performance, and rela…
67y · Female·Head injuries
Shirley Kidd, aged 67, died from head injuries inflicted by her grandson Hayden during a cannabis-induced psychosis. Hayden had experienced severe childhood abuse by his stepfather and subsequently developed mental healt…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suic…
61y · Male·hanging
Andrew Robert Young, a 61-year-old man with lifelong depression and social phobia, died by hanging on 13-14 January 2020. He had received consistent psychiatric care from an experienced psychiatrist for 16 years using su…
43y · Male·Hanging
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite cle…
42y · Female·Incised injury to the neck
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…
47y · Male·neck compression due to hanging
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…
45y · Female·Compression of the neck in circumstances of hanging
…ncipal In House Solicitor at the Coroners Court of Victoria with extensive qualifications and excellent performance record, took her life by hanging on 7 September 2018. In February 2018, she accepted a temporary acting…
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
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