Coronial

14 results for school disengagement

NSWhome2025-03-03

Inquest into the death of Harmony

15y · Female·hanging

…ied by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed cases due to "competing priorities…

paediatricspsychiatrysystemdelaycannabis
WA2025-12-17

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

14y · Female·ligature compression of the neck (hanging)

…hild protection and mental health services, poor coordination across agencies, failure to escalate her disengagement from school and psychology, and insufficient follow-up after psychiatric assessments. Her treating psy…

paediatricsgeneral practicecommunicationsystemmelatonin
VIChospital2024-07-25

Finding into death of Nathan Ruan Roy Greenwood

18y · Male·Sodium nitrite toxicity

Nathan Greenwood, an 18-year-old with a history of anxiety and depression managed in primary care, died from sodium nitrite toxicity after intentionally consuming 30 grams of the substance. He had been under care at his …

general practicepsychiatrysystemdelaysodium nitrite
VIChome2020-08-11

Finding into death of Angel Louise Hensgen

13y · Female·Acute paracetamol toxicity

…tressed 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 incide…

general practicetoxicologycommunicationsystemparacetamol
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
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
VIChospital2019-08-01

Finding into death of Tyla Jade Hovenbitzer

18y · Female·Multiorgan failure complicating malnutrition in a female with liver cirrhosis, o…

An 18-year-old female with Down syndrome, autism spectrum disorder, and severe intellectual disability died from multiorgan failure complicating severe malnutrition, non-alcoholic fatty liver disease, and obesity. She pr…

paediatricsgeneral practicesystemdelaytemazepam
VIChome2014-07-18

Finding into death of Shyra Lee Bloomfield

16y · Female·hanging

…hip breakdown. She had chronic substance abuse, complex psychosocial needs, learning difficulties, and disengagement from education. While Child Protection workers were conscientious and made appropriate referrals, syst…

paediatricsaddiction medicinesystemcommunicationinhalant
QLDhome2008-09-19

12 year old boy at Kowanyama

12y · Male·Suicide by hanging

A 12-year-old Aboriginal boy living in a remote Queensland community died by suicide by hanging following his placement in alternative care by child protection services. The boy had multiple vulnerabilities including fet…

paediatricspsychiatrydiagnosticsystem
SAcommunity2014-06-17

Coroner's Finding: HUGO-HORSMAN Jason William

15y · Male·compression of the neck consistent with hanging

…August when the social worker went on leave. (2) Failure to respond appropriately to escalating risk: when school counsellor Andrew Dunn reported suicidal ideation in June and August, this was not adequately documented o…

psychiatrypsychologydiagnosticcommunicationdiazepam
QLDhome2022-06-17

CJ - Non-inquest findings

14y · Male·Hanging

A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a trauma-infor…

paediatricspsychiatrydiagnosticcommunicationcannabis
TAScommunity2015

Coroner's Finding: Youth Suicide

Unknown·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
VIC2015-10-05

Finding into death of Catherine Jane Bernard

17y · Female·multiple injuries due to impact by train

A 17-year-old girl with major depressive disorder, a history of self-harm and overdoses, parent-child conflict, and a disclosed history of childhood sexual abuse died by suicide on her first day of Year 12. Critical clin…

emergency medicinepsychiatrycommunicationsystemtemazepam
NSWhome2023-08-22

Inquest into the death of George Campbell

17y · Male·hydrocarbon toxicity (petrol inhalation)

George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …

paediatricspsychiatrycommunicationsystempetrol

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