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38 results for suicidal ideation

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
VIC2015-11-05

Finding into death of Robert Keith Knight

62y · Male·Head injuries sustained in a fall from height

…013. He had been on remand for six months. Although Knight had no prior psychiatric history, he expressed suicidal ideation in intercepted letters (December 2012 and March 2013) and was appropriately placed under observa…

psychiatryemergency medicine
NSWhome2022-06-07

Findings - AD & Aleksander Stefanovic

Male·Gunshot wound to chest (Aleksander Stefanovic); gunshot wound to head (AD)

…ir shared Lewisham home on 4 September 2020. AD (aged 55), with documented depression, anxiety and recent suicidal ideation, shot his flatmate Aleksander Stefanovic (aged 36, recently commenced methadone for opioid use) …

emergency medicineparamedicine
QLDhome2015-03-19

Press, Connon Kenneth

33y · Male·Gunshot wound to the head

…3-year-old man with paranoid schizophrenia, polysubstance dependence (amphetamines/cannabis), and chronic suicidal ideation died from a self-inflicted gunshot wound to the head. He had been prescribed risperidone and pro…

psychiatryforensic medicinemethamphetamine
VIChospital2023-02-24

Finding into death of Justin Patrick Crome

39y · Male·Injuries sustained in a fall from the Camberwell train station bridge

…e contact. Critical clinical lessons include: (1) After ED presentation on 6 February 2020 with expressed suicidal ideation, there was inadequate follow-up contact within 24 hours despite missing three appointments in fo…

psychiatryemergency medicinecommunicationdelaypaliperidone
WAcommunity2026-05-27

Inquest into the Death of David GRAY

58y · Male·Gunshot injury to the abdomen

David Gray, 58, deliberately induced police to shoot him as a means of suicide following undisclosed mental health deterioration. On 22 September 2023, he called police anonymously reporting an armed person, then present…

emergency medicineforensic medicine
TAShome2018-03-05

Coroner's Finding: Bunn, Lauren Elizabeth

25y · Female·mixed drug toxicity

…e months preceding her death. After calling a counsellor from Rural Alive and Well reporting overdose and suicidal intent, a critical delay occurred: the police dispatch operator failed to simultaneously request an ambul…

psychiatryemergency medicinecommunicationsystem
SAhospital2025-06-11

Coroner's Finding: OHalloran, Emma Louise

48y · Female·multiple drug toxicity consisting of flecainide, lorazepam and diazepam

A 48-year-old woman died from multiple drug toxicity (flecainide, lorazepam, diazepam) following a deliberate overdose. She was located by police after a search and detained under the Mental Health Act. Critical delays o…

cardiologygeneral practicesystemcommunicationflecainide
NSWhome2024-12-09

Inquest into the death of Jet Gallagher

19y · Male·In keeping with hanging

… his brother's emergency call. Jet had consumed Valium and alcohol after losing money gambling, expressed suicidal intent to his brother, and disclosed overdose with intent. When paramedics assessed him, his presentation…

paramedicinepsychiatrycommunicationdiagnosticdiazepam
VIChospital2022-05-17

Finding into death of Mr J

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

… early January 2020, he presented to ED following ingestion of benzodiazepines and alcohol with ambiguous suicidal statements; he was discharged after brief assessment without formal mental health evaluation or GP notifi…

general practicepsychiatrycommunicationdiagnosticpaliperidone
QLDhome2026-06-17

Inquest into death of Steven Richard Angus

52y · Male·Gunshot wound to the chest

…elfare check on 21 April 2023. On the previous day, Steven presented to the emergency department in acute suicidal crisis while intoxicated, was assessed, and discharged home with community mental health follow-up arrang…

emergency medicinepsychiatrysystemcommunicationalcohol
NSWmental health2019-12-04

Inquest into the death of Mitchell FLOOD-SMITH

23y · Male·Multiple injuries sustained following collision with a train

…ft. Police were notified 30 minutes after absconding without critical information about his railway track ideation. The deceased died by deliberate train collision approximately 1 hour 51 minutes later. Clinical lessons …

psychiatryparamedicinecommunicationsystemrisperidone
NSWcommunity2017-08-17

Inquest into the death of MC

45y · Male·gunshot wound to the chest

A man with a long history of depression, suicide attempts, and previous violent behaviour died when shot by police during an arrest for domestic violence. His partner had repeatedly warned police that he threatened to ma…

psychiatrygeneral practicecommunicationdiagnostic
VIChospital2023-12-13

Finding into death of RW C

43y · Male·exsanguination from incised wounds to the arms - self inflicted

…s limited to two brief phone calls for appointment arrangement purposes, without documented assessment of suicidal ideation, psychotic symptoms, or illicit drug use—all high-risk factors. When he missed a scheduled psych…

psychiatryemergency medicinecommunicationdelayrisperidone
SA2015-06-24

Coroner's Finding: HARDING-ROOTS Jeremy Godfrey

47y · Male·Toxic effects of phosphine gas

Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…

psychiatrygeneral practicediagnosticsystemoxazepam
VICmental health2013-02-25

Finding into death of Joy Apostolopoulos

41y · Female·Multiple injuries due to impact by train

Joy Apostolopoulos, a 41-year-old woman with schizophrenia and depression, died by suicide when struck by a train after absconding from a locked psychiatric ward at Alfred Hospital. She had been on escorted leave, became…

psychiatryemergency medicinecommunicationsystemclozapine
NThospital2005-08-31

Inquest into the death of Marcellus Tipiloura

26y · Male·Suicidal cut throat

A 26-year-old Aboriginal male, Marcellus Tipiloura, died from a self-inflicted cut throat while police and emergency services were attending. He had made threats to kill himself and his wife after consuming alcohol and c…

emergency medicineforensic medicinemidazolam
NSWhome2025-05-09

Inquest into the death of Malcolm Brown

33y · Male·sharp force injuries of the neck

Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 following a NSW Police operation.…

psychiatrytoxicologycommunicationdelaymethamphetamine
NSWhome2026-04-01

Inquest into the death of EJJ

39y · Male·Hanging

A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …

psychiatryforensic medicinecommunicationsystemdiazepam
VIChome2015-10-08

Finding into death of Bruce Desmond Andrews

60y · Male·medication overdose

Bruce Andrews, a 60-year-old man with major depression and anxiety, died from medication overdose following relationship breakdown and acute alcohol intoxication. He fell from his porch, called his granddaughter reportin…

psychiatryemergency medicinecommunicationdiagnosticclonazepam

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