Coronial

27 results for suicidal ideation (past history)

WA2001-11-19

Inquest into the Death of Adam Timothy Garner

18y · Male·Ligature Compression of Neck (Hanging)

…tory of contemplating suicide during stress and ADHD diagnosis, he misled reception staff by denying past suicidal ideation. Prison medical staff assessed him as low risk based on his presentation and lack of access to h…

correctional healthpsychiatrysystemcommunicationprescription medication for alcohol and drug withdrawal
WAhome2002-07-05

Inquest into the Death of Bradley William Rapley

22y · Male·Hypoxic Ischaemic Encephalopathy due to suffocation

…a drug debt. On the evening of 25 August, after an emotional visit with his girlfriend where he expressed suicidal ideation, and following perceived insensitive comments from prison officers about medication timing, Rapl…

psychiatrygeneral practicesystemcommunicationdosulepin
VIChome2012-02-14

Finding into death of Edo Travaglia

54y · Male·Carbon monoxide poisoning

Edo Travaglia, a 54-year-old carer for two adult sons with profound disabilities, died of carbon monoxide poisoning along with his sons in an apparent murder-suicide. Despite significant improvement in his sons' care fol…

psychiatrygeneral practicebenzodiazepines
TAScommunity2021-09-02

Coroner's Finding: Sterling, Barbara Lynette

69y · Female·Drowning

Barbara Lynette Sterling, a 69-year-old woman living in independent retirement accommodation, was found drowned in the River Derwent on 19 July 2020, having been last seen dropped by taxi near the location on 18 July eve…

forensic medicinegeneral practice
WA2002-01-11

Inquest into the Death of Leslie William Wesley

32y · Male·Ligature Compression of Neck (Hanging)

… without discernible triggers on the day. Wesley had been assessed earlier in his detention as expressing suicidal ideation and self-harm behavior, but staff found no specific risk on 7 May 2000. The coroner found no cau…

psychiatrycorrectional health
VIC2024-10-14

Finding into death of Scott Alan Murdoch

43y · Male·Amitriptyline toxicity

Scott Alan Murdoch, a 43-year-old maximum-security prisoner with chronic suicidal ideation, borderline personality disorder, and a documented history of medication hoarding and overdose a…

psychiatrycorrectional healthmedicationsystemamitriptyline
SA2019-12-20

Coroner's Finding: MORGAN Martina

60y · Female·neck compression by ligature strangulation

…d have been classified as 'high need' rather than 'medium risk' based on her gross intoxication, reported suicidal history, PTSD diagnosis, and assertion of recent overdose. Mandatory 15-minute observations and CCTV moni…

diagnosticcommunicationalcohol
QLDhospital2013-01-18

Ryan, Adam Trent

30y · Male·asphyxia due to hanging (suicide)

30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…

psychiatrygeneral practicecommunicationdocumentationsertraline
QLD2023-09-19

AJO - findings

34y · Male·Hanging

A 34-year-old remand prisoner died by hanging in his cell at Arthur Gorrie Correctional Centre. He had a history of child sexual offences and mental health issues including depression and past self-harm. Initial risk ass…

psychiatrycorrectional healthcannabis
VICmental health2014-12-19

Finding into death of Melissa Jane Thorn

33y · Female·multiple injuries sustained in a train incident

A 33-year-old woman with schizoaffective disorder and chronic suicidality died by suicide after stepping in front of a train on 6 October 2009. She was an involuntary psychiatr…

psychiatryemergency medicinesystemcommunicationclozapine
VIC2022-07-28

Finding into death of Master S

17y · Male·Unascertained in the setting of volatile substance abuse

…exona deodorant). He had a history of exposure to family violence, ADHD, mental health concerns including suicidal ideation, contact with child protection and youth justice systems, and was living in youth accommodation.…

paediatricspsychiatrycommunicationsystemrexona deodorant
QLDcommunity2024-11-04

Inquest into the death of Damon Paul William Savage

27y · Male·Multiple gunshot wounds

…and was shot after a Taser proved ineffective. He had a documented history of ICE dependence, depression, suicidal ideation, anger management issues, and recent domestic violence. Mental health services had assessed him …

psychiatryemergency medicinecommunicationsystemmethamphetamine
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
VIChospital2015-08-28

Finding into death of Moufid Sawan

61y · Male·Complications of cutaneous burns

A 61-year-old man with severe chronic schizophrenia and extensive history of arson, suicide attempts and self-harm was admitted as a voluntary patient to a psychiatric inpatient unit and later made involuntary. Despite c…

psychiatryemergency medicinecommunicationdiagnosticrisperidone
SAhome2014-06-17

Coroner's Finding: KOLBIG Drew Robin

37y · Male·stab wound to the chest penetrating the heart

… and command hallucinations instructing self-harm. On 20 April, he presented to emergency department with suicidal ideation and to his psychiatrist with delusional paranoia—neither event prompted reassessment or hospital…

psychiatryoccupational therapydiagnosticcommunicationquetiapine
QLD2013-05-27

Hussain, Meqdad

19y · Male·Hanging

Meqdad Hussain, a 19-year-old Afghan asylum seeker, died by hanging in an immigration detention centre (Scherger IDC, Queensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted …

psychiatrygeneral medicinesystemcommunicationmirtazapine
NSWcommunity2026-03-30

Inquest into the deaths of Noah and Wayne Smith

Male·Gunshot wounds to the head

… Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recovered with antidepressants and l…

general practicepsychiatrydiagnosticcommunicationvenlafaxine
VIChospital2023-01-18

Finding into death of S J

24y · Male·Injuries sustained in fall from height

…enth-floor rooftop garden of Peter MacCallum Cancer Centre. Despite a history of depression with previous suicidal ideation, SJ was assessed as low-risk by his mental health team and appeared clinically stable and engage…

psychiatryhaematologycommunicationdelaymetoclopramide
QLDcommunity2023-11-17

MOLAYEE, Omid (Farsi Translation)

43y · Male·Gunshot wounds to the chest; exsanguination and respiratory failure secondary to…

Imad Damouni (43) died from gunshot wounds to the chest after self-immolating with petrol in a parking lot in Sunnybank, Brisbane on 6 April 2020, following a domestic dispute. Police responded appropriately to a suicide…

emergency medicinetrauma surgerymethamphetamine
VICcommunity2012-11-30

Finding into death of Simon Kirwan

19y · Male·Ruptured aorta post motor vehicle incident

…s discharged from St Vincent's Hospital on 23 November 2008 after clinicians assessed he was not actively suicidal and didn't meet involuntary detention criteria. Critical failings included: incomplete assessment of his …

psychiatryemergency medicinediagnosticcommunicationdiazepam

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