Coronial

293 results for suicidal behaviour

VIChome2024-01-10

Finding into death of Ya (Cindy) Zhao

28y · Female·Effects of fire

… on 22 July 2022. She had schizophrenia with a history of mental health crises, depression, self-harm and suicidal ideation. She was living independently with outpatient support from Eastern Health, though services were …

psychiatryemergency medicineamisulpride
VIChome2020-09-11

Finding into death of Mr A

44y · Male·compression of the neck consequent upon hanging

…er violence died by hanging. He had recently separated from his wife and was enrolled in a 18-week men's behaviour change program, having completed 17 of 18 sessions. He reported suicidal ideation and lowered mood but d…

general practicepsychiatrysystemdelayalcohol
VICcommunity2010-06-11

Finding into death of Kelvin Lea Swab

34y · Male·Hanging

…wab, a 34-year-old with chronic mental illness including borderline personality disorder and longstanding suicidal ideation, died by hanging on 12 October 2008, shortly after discharge from inpatient psychiatric care. He…

psychiatrycommunicationdiazepam
VICcommunity2020-05-01

Finding into death of Joelene Therese Dowden

37y · Female·Hypoxic ischaemic brain injury complicating aspiration of gastric contents

…ollowing aspiration of gastric contents. She presented at Alfred Hospital ED on 9 July 2017 with erratic behaviour, then went to a tram stop where she expressed suicidal intent and collided with a tram. Police arrested …

emergency medicineintensive caredoxylamine
VIChospital2018-06-20

Finding into death of Amanda Dawson

57y · Female·Head injuries resulting in subdural haematoma and global cerebral ischaemic inju…

…ree days later. The coroner identified multiple family violence risk factors in Masatora: mental illness, suicidal ideation, obsessive and jealous behaviour, stalking, and unemployment. Critical clinical lessons include …

trauma surgeryneurosurgeryrisperidone
VIChospital2014-11-28

Finding into death of Taylor Page Janssen

16y · Female·Multisystem organ failure and cerebral hypoxia secondary to hanging

…relevant to youth suicide prevention. Taylor had searched online for hanging information and demonstrated suicidal planning. The coroner noted that while Western Heights Secondary College and local services provided supp…

psychiatryemergency medicinesystem
VIChome2012-12-12

Finding into death of B K

Female·Hanging

…tory of heroin abuse, benzodiazepine misuse, and mental health issues including depression and psychotic behaviour. She received treatment for opiate dependence at North Yarra Community Health but with poor engagement a…

addiction medicinepsychiatryheroin
VIC2014-09-11

Finding into death of Lloyd Felman

58y · Male·Amitriptyline toxicity

…city in July 2008. In the three weeks prior, he presented to hospital three times with bizarre high-risk behaviours (exhaust hose scenarios) while denying suicidal intent. Despite unusual presentations, psychiatrists at…

psychiatryemergency medicineamitriptyline
WA2018-05-31

Inquest into the Death of Giuseppe DEL BORRELLO

78y · Male·unascertained

…educed autonomy, family tension about further moves), missing sleeping tablets, and statements suggesting suicidal ideation. He disappeared into a remote area without food or water during summer heat. Despite comprehensi…

general practicepsychiatrynitrazepam
TAShome2020-07-16

Coroner's Finding: Alsop, Olaf Paul

54y · Male·asphyxia due to hanging

…scalating requests for pain medication. His GP ceased treatment due to concerns about medication-seeking behaviour and dishonesty about drug use. The patient became distressed at losing his GP but was offered alternativ…

general practicepalliative carecodeine
TAScommunity2018-03-19

Coroner's Finding: Hamlyn, Michael William

Male·hanging

…after. The clinical lesson here relates to continuity of mental health care: young people presenting with suicidal behaviour require comprehensive assessment, documented treatment plans, and appropriate follow-up engagem…

psychiatryemergency medicinesystem
VIChome2010-07-21

Finding into death of MF

29y · Female·Multiple stab wounds to the neck

…inical lessons include: GPs must recognise family violence risk factors (pending separation, controlling behaviour, mental health issues, suicidal ideation) and proactively refer to specialist family violence services r…

general practiceforensic medicinecommunicationsystem
VICcommunity2016-12-14

Finding into death of Jake James-Kotsanas

23y · Male·Haemorrhage from incised wounds to the neck and wrists

…ere identified. The case highlights the challenge of managing acute drug-induced psychosis complicated by suicidal behaviour in crisis settings.

psychiatrytoxicologymethamphetamine
NThome2001-01-25

Inquest into the death of Eduardo Concepcion

26y · Male·multiple gunshot wounds with death resulting from combination of blood loss and …

Eduardo Concepcion, a 26-year-old man experiencing mental health crisis and acute intoxication, died from multiple gunshot wounds inflicted by Northern Territory Police. Following days of deteriorating mental state, self…

emergency medicinepsychiatrysystemcommunicationmogodons
VICcommunity2010-05-19

Finding into death of Ali Sultan Zaidi

30y · Male·head and chest injuries sustained in a fall from a height

…n 24 September 2007. He had a psychiatric review on 20 September 2007 with Dr M., who assessed him as non-suicidal, reviewed his medications (Lithium, Risperidone, and added Olanzapine), and found no basis for involuntar…

psychiatryforensic medicinelithium
QLDcommunity2024-10-11

Findings of the inquest into the death of Luke Brian Gilbert

24y · Male·Gunshot wounds to the chest

… lessons include: Luke had documented alcohol use disorder, antisocial personality disorder, and previous suicidal ideation with self-harm scarring. He presented to hospital with suicidal ideation 9 days before death but…

emergency medicinepsychiatryalcohol
NSWcommunity2024-12-18

Inquest into the death of Olivia Gilffillan

23y · Female·unascertained

…d as important. Between discharge and her death, she had four brief hospital admissions for self-harm and suicidal ideation. On 1 February 2018, after her case worker arranged hospital assessment against her wishes, Oliv…

psychiatryemergency medicinesystemclozapine
TAShome2022-09-20

Coroner's Finding: Hill, Sandra Germaine

67y · Female·mixed prescription drug toxicity (oxycodone and oxazepam); central nervous syste…

…ith her partner, she self-administered a fatal overdose of oxycodone and oxazepam tablets with documented suicidal intent (notes left, 'DNR' written on chest, farewell text message). Her prescriber appropriately assessed…

general practiceoncologyoxycodone
VIChome2011-08-15

Finding into death of James Martin Todd

41y · Male·Neck compression subsequent upon hanging

A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by hi…

general practicepsychiatrysystemdelayparoxetine
VICmental health2016-05-13

Finding into death of Shaun Luke Beagley

33y · Male·Mixed drug toxicity

…rch 2014, RPN Pollock approved overnight leave after brief assessment, though Shaun had reported fleeting suicidal ideation in the preceding 48 hours and had not shown improvement in withdrawn behaviour. Critical omissio…

psychiatryassessmentcommunicationheroin
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