Coronial

181 results for poor medication compliance

TAScommunity2018-10-18

Coroner's Finding: MacQueen, Tyrone Frederick

25y · Male·unable to determine

Tyrone Frederick MacQueen disappeared on 1 July 1994 at age 25. He had chronic schizophrenia with poor medication compliance, recent psychiatric hospitalization, expressed suicidal ideation, self-harm (wrist cu…

psychiatrygeneral practicesystemdelaysuromtil
VICcommunity2022-11-15

Finding into death of Katica Perinovic

42y · Female·Multiple stab wounds

…vices in November 2020 after acute onset of paranoid delusions. She was commenced on risperidone but showed poor engagement and medication compliance. Between December 2020 and January 2021, clinical review was predomina…

psychiatrygeneral practicediagnosticcommunicationrisperidone
SAhospital2018-07-27

Coroner's Finding: CUTTS Charles Desmond

70y · Male·aspiration pneumonia due to seizures

…wing seizures while admitted under mental health legislation. He was subject to multiple comorbidities with poor medication compliance. Clinical decline was marked by acute delirium and confusion on admission (possibly a…

emergency medicinepsychiatryrisperidone
VICcommunity2011-10-26

Finding into death of Redae Berhane

23y · Male·Unknown - missing person, no conclusive evidence of death

…ns (2004, 2006, 2007) and was under community treatment order. His treating mental health team noted he had poor insight into his illness, medication non-compliance, and considerable difficulty functioning independently …

psychiatrycommunicationsystemrisperidone consta
VICcommunity2015-04-09

Finding into death of Tomislav Brekalo

29y · Male·Injuries sustained in a fall from a height

…ar history of psychiatric illness with recurrent psychotic episodes despite treatment with antipsychotic medications including olanzapine. In the months before death, his mental health deteriorated significantly; he lost…

psychiatrygeneral practicecommunicationsystemolanzapine
NSWcommunity2021-10-22

Inquest into the death of Liselle HOUBERT

23y · Female·Multiple injuries received in a deliberate motor vehicle collision

…ncluding depression, PTSD, anxiety and panic disorder. He had been prescribed multiple antidepressants with poor compliance. Two days before the collision, his doctor ceased medication due to side effects with a planned …

psychiatrygeneral practiceantidepressant medications
QLDcommunity2017-08-17

JJKD - Non-inquest findings

34y · Male·drowning

…ed 15-20), missed clinical escalation opportunities despite multiple warning signs (McDonald's incident, medication non-compliance, illicit drug use, family concerns), and failure to implement structured case reviews. Th…

psychiatrycommunicationsystemclozapine
VICcommunity2014-01-30

Finding into death of Mihail Andrinopoulos

73y · Male·UNASCERTAINED

…rt Phillip Bay. He had recently commenced dialysis after years of progressive kidney disease and documented poor medication compliance. He had chronic major depressive disorder with documented suicidal ideation explored …

general practicenephrology
NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

34y · Female·not able to be determined - body not found

…ospital on 22 August 2022. She had been admitted for a psychotic relapse with paranoid delusions related to poor medication compliance. Despite recent improvement during hospitalisation and community mental health follow…

psychiatrysystemcommunicationclozapine
VIChome2021-05-05

Finding into death of Aziza Beck

3y · Female·gunshot wound to the head

…tic Disorder (diagnosed 2015), was on olanzapine 15mg prescribed by a psychiatrist, but had a pattern of medication non-compliance (adjusting doses without medical advice). Key clinical lessons: the referring psychiatris…

psychiatrygeneral practicecommunicationsystemolanzapine
TAS2021-03-19

Coroner's Finding: Hyatt, Saxon George

55y · Male·exsanguination resulting from self-inflicted wounds to left brachial artery and …

… a long history of mental health conditions including schizophrenia, bipolar disorder, and depression, with poor medication compliance and heavy alcohol use. Prison health assessments were conducted appropriately on admi…

psychiatrycorrectional healthduloxetine
VIChome2022-11-15

Finding into death of Matthew Perinovic

3y · Male·Multiple stab wounds to the back

…assessments); failure to provide psychoeducation as documented in treatment plans; lack of monitoring of medication compliance despite recognised non-compliance risk; absence of formal mental state and risk assessments; …

psychiatrygeneral practicecommunicationsystemrisperidone
VIChome2022-11-15

Finding into death of Claire Perinovic

7y · Female·Multiple stab wounds to the back

…face contact after December 2020, lack of formal mental state and risk assessments, absent psychoeducation, poor medication compliance monitoring, failure to detect a risperidone overdose, and inadequate family involveme…

psychiatrygeneral practicecommunicationsystemrisperidone
VICmental health2011-04-20

Finding into death of Nigel Delaney

51y · Male·unascertained

…. Post-mortem examination, including toxicology, failed to determine a cause of death. The coroner found medication levels were therapeutic and within reasonable management parameters. Family concerns about over-medicati…

psychiatryforensic medicineolanzapine
ACTcommunity2015-06-30

INQUEST INTO THE DEATH OF MARK RODNEY JOLLIFFE

37y · Male·Hanging, self-inflicted with intention of taking own life

A 37-year-old man with schizophrenia and a history of medication non-compliance died by suicide while subject to a Psychiatric Treatment Order. He was last seen alive on…

psychiatrycommunicationzuclopenthixol
QLD2010-04-16

Nguyen, Luong Bang

31y · Male·Subarachnoid haemorrhage due to or as a consequence of a ruptured large fusiform…

…y was immaterial given the extensive brain injury was unsurvivable. He had been prescribed antipsychotic medication (Seroquel) for auditory hallucinations but had poor medication compliance. The coroner found the medical…

emergency medicineintensive carequetiapine
WAcommunity

Inquest into the Death of Dean Anthony POLLARD

41y · Male·unknown

…ital where psychiatric assessment found no acute risks despite chronic substance use and aggression. He had poor medication compliance, escalating drug dependence, and episodes of violence. Clinical lessons include: psyc…

psychiatryemergency medicinesystemcommunicationmethamphetamine
SAhospital2014-05-19

Coroner's Finding: AYRES David Stanley

65y · Male·sepsis due to aspiration pneumonia

…ty showed only 5 of approximately 20 expected antibiotic doses were recorded, though inventory suggested medication was likely administered but poorly documented. He was admitted to hospital on 14 June with community-acq…

general practiceintensive caresystemcefalexin
VICcommunity2014-08-25

Finding into death of Travis Joseph Hartskeerl

32y · Male·Head and neck trauma (train impact)

…, antidepressants, and anticholinergics. Critically, Travis ceased depot injections after discharge and had poor medication compliance. The coroner found no negligence or departure from professional standards by clinicia…

psychiatrygeneral practicecommunicationsystemzuclopenthixol decanoate
VIChome2010-04-27

Finding into death of David Mathew Smith

32y · Male·plastic bag asphyxia

… injections and forensic counselling. Smith rejected his mental illness diagnosis, refused antipsychotic medication, and experienced clinical depression in September 2007. Following an attempted suicide on 2 September, h…

psychiatryforensic medicinemedicationcommunicationrisperidone
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