19y · Female·Neck compression; Hanging
…ginal community. The coroner noted the difficulty in predicting suicide risk in individuals with recent situational crises who have given no warning signs, and commended coordinated postvention responses by the Victoria…
Male·consistent with the history of hanging
…n charged with serious offences and refused bail. Justice Health conducted initial screening, diagnosed situational crisis with low self-harm risk, and maintained monitoring for hypertension. The deceased reported the p…
32y · Female·Cerebral destruction caused by a self-inflicted bullet wound to the head
…ood alcohol level of 0.15% (over three times the legal driving limit). She was experiencing significant situational crisis: recent breakdown of her 16-year marriage, inability to reconcile with her estranged husband's n…
16y · Female·hanging
…n integrated treatment for co-occurring substance abuse and mental health risk. Early identification of situational crises (relationship loss during active intoxication) is critical.
34y · Male·Mixed drug toxicity
…essed to his case worker that he would overdose if discharged. Despite these threats, he was discharged to crisis accommodation at Hanover House with no psychiatric follow-up arranged. He died by overdose on 24 April 200…
50y · Male·hanging
…brother's suicide in April 2011, he increased substance use. On 1 July 2012, he called Mercy Mental Health Crisis Assessment and Treatment Team stating he wanted to hang himself and was actively attempting to tie a noose…
73y · Male·Stab wound to the neck
…al ideation and exhibiting paranoid ideation about the ATO to her psychologist, appropriate escalation and crisis intervention did not occur. The coroner noted that carer fatigue was a significant situational stressor; r…
56y · Male·Hanging
A 56-year-old man with a long history of bipolar affective disorder and alcohol misuse died by hanging between 18–20 December 2018. He presented to hospital on 16 December after expressing suicidal intent (plan to overdo…
34y · Male·hypoxic encephalopathy following hanging
Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody afte…
18y · Male·Effects of fire (accidental)
…barriers; however, the case also highlights how substance use (methamphetamine) may impair judgment and situational awareness in crisis situations. The coincidence of the fire occurring on the night Daniel feared a home…
27y · Male·Gunshot wound to the chest fired by Sergeant Matthew Gale of the Australian Fede…
… Doherty, aged 27, died from a gunshot wound inflicted by AFP Sergeant Matthew Gale during a mental health crisis. Nathan had a long history of depression, anxiety, and alcohol abuse, with two prior suicide attempts by o…
28y · Male·Hanging
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal ideation and paracetamol overdose. The coroner foun…
46y · Male·neck compression due to hanging
Matthew Wade Sulley, aged 46, died by hanging while on home detention under Department for Correctional Services supervision. He had a significant psychiatric history including previous suicide attempt by hanging (1997),…
34y · Male·neck compression due to hanging
A 34-year-old male on home detention bail died by hanging. He had a history of mental health issues, depression, and prior suicide threats, but did not disclose these to correctional services staff. In the 24 hours befor…
28y · Male·Hanging
Dylan Bell, 28, died by hanging following discharge from Redland Hospital ED where he presented with acute psychosis, suicidal and homicidal ideation, and made three self-harm attempts by strangulation. Despite a concern…
46y · Female·Combined drug toxicity in a woman found in a bath
…ple mental health services. Critical clinical lessons include: (1) improved handover communication between crisis teams and day staff after high-risk calls is essential—Ms S disclosed a medication stockpile and suicidal …
22y · Female·compression of the neck consistent with hanging
22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…
37y · Male·compression of the neck consistent with hanging
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened …
26y · Female·compression of the neck consequent upon hanging
…ic admission. She had presented to emergency with acute suicidality on 18 June, attended police station in crisis on 21 June, and was admitted on 21 June via Section 10 Mental Health Act order. Despite expressing repeate…
31y · Male·ligature compression of the neck (hanging)
A 31-year-old man with depression, suicidal ideation, and recent HIV diagnosis presented to emergency department after suicide attempt (carbon monoxide inhalation and diazepam overdose). Despite psychiatrists identifying…
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