Coronial

43 results for psychotic relapse risk

NSWcommunity2025-10-31

Inquest into the disappearance and suspected death of Sana Salman

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

…022 after being discharged from Northern Beaches Hospital on 22 August 2022. She had been admitted for a psychotic relapse with paranoid delusions related to poor medication compliance. Despite recent improvement during…

psychiatrysystemcommunicationclozapine
VICmental health2014-02-10

Finding into death of Frank (Francesco) Sette

72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall

…loor of a psychiatric ward. He was an involuntary patient in the High Dependency Unit experiencing acute psychotic relapse with command hallucinations. Clinical staff were present and responding appropriately to his acu…

psychiatrygeriatric medicinesodium valproate
WAcommunity2023-10-20

Inquest into the Death of Ashley Dean FILDES

34y · Male·gunshot injuries to the torso

… multiple people at a shopping centre while in acute psychosis. He had been non-compliant with depot antipsychotic medication for four months following his discharge from mental health services in March 2020. The corone…

psychiatryemergency medicinepaliperidone depot
WAmental health2023-02-13

Inquest into the Death of Philip SULLEY

58y · Male·coronary artery arteriosclerosis (natural causes)

…tley Mental Health Unit. He presented to Royal Perth Hospital emergency department on 19 April 2020 with psychotic behaviour but was discharged; his presentation was judged appropriate at the time despite later appearin…

psychiatryemergency medicinecommunicationolanzapine
TAShospital2022-03-21

Coroner's Finding: Rouse, Rex

86y · Male·pulmonary embolism following deep vein thrombosis

…n General Hospital on 26 May 2020. He was admitted under a Mental Health Act assessment order following a relapse of psychotic depression at his aged care facility. Clinical examination found no acute cause for his ment…

psychiatryemergency medicinemirtazapine
VIChome2019-08-15

Finding into death of Jovan Kozarov

62y · Male·Incised wound to the neck

A 62-year-old man died from an incised neck wound inflicted by his son during a psychotic relapse. The son, with a 15-year history of schizophrenia managed in the community, was experiencing wor…

psychiatryforensic medicinecommunicationsystem
WAmental health2014-04-11

Inquest into the Death of Rutherford Sarah

28y · Female·multiple injuries from deliberate fall from pedestrian bridge onto Mitchell Free…

…She was an involuntary patient at Graylands Hospital at the time, admitted on 3 December 2009 following a relapse triggered by non-compliance with antipsychotic medication. After initial stabilisation on a secure ward w…

psychiatryintensive carerisperidone
NSWcommunity2025-08-25

Inquest into the death of Ashley Paull

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

…service failed to escalate appropriately after Sandra reported concerning behavioural changes suggesting psychotic relapse, including that community mental health did not contact the rapid response service or police des…

psychiatryemergency medicinecommunicationsystemmethamphetamine
NSWcommunity2025-03-06

Inquest into the death of Fiona Turnbull

59y · Female·multiple injuries from fall from height

…pine, died from multiple injuries after falling from her third-floor balcony on 12 October 2017 during a psychotic relapse. The death occurred shortly after the unexpected death of her long-term partner and de facto fat…

psychiatryemergency medicinedelaycommunicationclozapine
VICmental health2024-09-30

Finding into death of Erol Elmas

31y · Male·undetermined

…ains undetermined despite thorough pathological investigation. Mr Elmas was in seclusion following acute psychotic relapse and violent behaviour. Critical clinical lessons include: (1) vital signs monitoring during secl…

psychiatryemergency medicinesystemdelayzuclopenthixol acetate
TAScommunity2021-11-18

Coroner's Finding: Wheldon, Jamie Damien

45y · Male·methylenedioxymethylamphetamine (MDMA or 'ecstasy') toxicity

…DMA toxicity on 29 December 2019. He was on approved leave from the Salvation Army Bridge Program when he relapsed, obtaining and ingesting MDMA. His reduced tolerance following abstinence may have contributed to fatal …

addiction medicinepsychiatryMDMA
WAcommunity

Inquest into the Death of Sarah Jane RUTHERFORD

28y · Female·multiple injuries

…following medication non-compliance and suicidal ideation. Her condition improved significantly with antipsychotic medication; she was discharged to family care on 23 December with a seven-day prescription and expected …

psychiatryemergency medicinerisperidone
SAcommunity2006-12-13

Coroner's Finding: ELDRIDGE Michael and GERARD David

Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…

…unity Treatment Order (CTO) or adequate follow-up arrangements, despite documented violence and predictable risk of relapse with substance abuse. Barry Simper fatally stabbed Michael Eldridge in 2003 six days after disch…

psychiatryemergency medicinecommunicationsystemzuclopenthixol deconate
VICcommunity2017-09-13

Finding into death of Luis Lopez

52y · Male·hanging

… failed to attend a clinic appointment. The following day, psychiatric nurses administered his depot antipsychotic injection at home; Lopez appeared calm, cooperative, and denied concerns. He left the flat that afternoo…

psychiatryemergency medicinepaliperidone
VIChome2015-04-13

Finding into death of Athiel Deng

59y · Female·head injury

…thiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in Fe…

psychiatryemergency medicinesystemdelaycannabis
VICmental health2012-10-12

Finding into death of Grant Elliot Phillips

29y · Male·Multiple injuries sustained in a train incident (intentional self-harm)

…it (HDU) may have been inappropriate given recent CTO revocation for non-compliance and significant suicide risk; however, even HDU admission with a weekend stay may not have altered outcome as risk was reassessed as man…

psychiatrydiagnosticsystemdextroamphetamine
NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

…ting that his treating psychiatrist Dr B.-Lavack failed to adequately monitor him after cessation of antipsychotic medications from June 2018, did not respond appropriately to early warning signs of relapse reported by …

psychiatrygeneral practicecommunicationsystemclozapine
VICmental health2015-07-08

Finding into death of David Allan D'Angelo

30y · Male·Heroin toxicity

…polysubstance dependence, was admitted to The Alfred Psychiatric Unit involuntarily on 24 March 2010 for psychotic relapse. His symptoms improved rapidly with antipsychotic medication, and by 6 April he was transferred …

psychiatryemergency medicinesystemdelayheroin
VIChospital2022-05-17

Finding into death of Mr J

36y · Male·Multiple Sharp Force Injuries to Chest and Neck

Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with G…

general practicepsychiatrycommunicationdiagnosticpaliperidone
NSWmental health2026-02-05

Inquest into the deaths at Westfield Bondi Junction Executive Summary

41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…

…nagement in Queensland before the attack. Key clinical failures identified: (1) gradual cessation of antipsychotic medications (clozapine 2012–2018) without adequate monitoring; (2) inadequate response to early warning …

psychiatrygeneral practicediagnosticcommunicationclozapine

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