Coronial

12 results for poor school attendance

SAhospital2009-05-22

Coroner's Finding: ROBERTS Jarrad Delroy

10y · Male·sepsis (fusobacterium necrophorum) complicating right otitis media

…systemic failures included: mother's severe untreated post-traumatic stress disorder and neglect; extremely poor living conditions; chronic school non-attendance (65 of 76 days absent in first half of 2006, then zero att…

paediatricsgeneral practicedelaysystemamoxicillin
WAhome2021-04-16

Inquest into the Death of Child LDW (Name Subject to Suppression Order)

3y · Female·tramadol toxicity

…scalate concerns about the carer's deteriorating capacity, depression, illicit drug use, and the children's poor school/daycare attendance. Geographic distance from the office, inadequate new-worker training, and failure…

paediatricsforensic medicinesystemdelaytramadol
NThome2024-06-27

Inquest into the death of Grace

13y · Female·Self-inflicted single gunshot wound to the chest

…n unsecured .308 Winchester rifle stored in her parents' bedroom. She had disclosed suicidal thoughts to a school counsellor in September 2021, but this disclosure was not adequately responded to. Key clinical lessons in…

psychiatrypaediatricsdiagnosticcommunication
VIChome2021-06-29

Finding into death of HM

15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…

…oration with early peritonitis secondary to acute gastric distension. He had dysfunctional eating patterns, poor school attendance, social isolation, and refused medical follow-up. HM did not communicate symptoms to pare…

paediatricspsychiatrysystemdelaylovan
VIChome2020-08-11

Finding into death of Angel Louise Hensgen

13y · Female·Acute paracetamol toxicity

…g, distressed by family relationships, peer conflicts, and a relationship breakdown, all while experiencing poor school engagement and self-harming. Red Cliffs Secondary College staff responded appropriately to specific …

general practicetoxicologycommunicationsystemparacetamol
NTcommunity2020-12-15

Inquest into the death of Fionica James, Katurah Mamarika, Layla Leering

Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…

…multiple notifications; inadequate mandatory reporting of domestic violence and sexual assault; inadequate school attendance monitoring despite statutory obligations; perfunctory police investigations; and absence of tra…

paediatricspsychiatrydiagnosticcommunicationalcohol
QLDhome2010-03-05

Child at Mackay

15y · Female·Ligature compression of the neck (hanging)

…transient lifestyle with unstable housing, moved frequently between relatives, was not regularly attending school, and engaged in substance abuse (paint sniffing, alcohol). She was unsupervised and out late drinking with…

paediatricspsychiatrysystemdelayalcohol
VICcommunity2011-05-16

Finding into death of Aaron

14y · Male·injuries sustained in fall from height

…ad 14 child protection notifications for exposure to domestic violence, neglect, parental substance misuse, poor school attendance, and homelessness. The coroner found that DHS failed to conduct proper mental health asse…

paediatricspsychiatrydiagnosticsystem
NTcommunity2020-12-15

Inquest into the death of Master W, Miss B and Master JK

volatile substance abuse (inhalation of petroleum vapour, aviation fuel, deodora…

…harge; failure to escalate to the Chief Health Officer; gaps in inter-agency communication; and inadequate school engagement. The coroner found the Top End Health Service continued unlawful practices despite earlier 2017…

psychiatryaddiction medicinediagnosticsystempetrol
VICcommunity2017-04-05

Finding into death of KP

15y · Male·Hanging (redacted in original but indicated by reference to method of suicide)

A 15-year-old boy with depression died by suicide. He had a difficult relationship with his parents and was reluctant to engage with mental health services. A clinical psychologist assessed him as low-moderate suicide ri…

psychologypsychiatrycommunicationsystem
TAScommunity2015

Coroner's Finding: Youth Suicide

suicide by hanging or other means

… All had significant mental health issues, trauma histories, and contact with child protection services or schools. The coroner identified systemic failures in child protection risk assessment (particularly cumulative ha…

psychiatrypaediatricssystemcommunicationlamotrigine
WAcommunity2019-02-07

Inquest into the 13 Deaths of Children and Young Persons in the Kimberley Region

Ligature compression of the neck (hanging) in 12 cases; one open finding

…ergenerational trauma, exposure to domestic violence and alcohol abuse, untreated mental health conditions, poor physical health (failure to thrive, recurrent infections), and inadequate access to culturally appropriate …

psychiatrypaediatricsdiagnosticcommunicationalcohol

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