Coronial

10 results for suicidal ideation (undisclosed)

VIC2016-04-01

Finding into death of Dianne Chi

23y · Female·blood loss from an abdominal stab wound and from incised injuries to the head

…tly died by carbon monoxide poisoning. The coroner found that Pham chose not to disclose his homicidal or suicidal feelings, anger, or depression to loved ones or medical practitioners. This case highlights the critical …

pathologyforensic medicine
NSWhospital2017-12-21

Inquest into the death of Errol Handog

34y · Male·Hanging

…ssessed by psychiatry on two consecutive days at Nepean Hospital and discharged to community care despite suicidal ideation. A key clinical lesson is that incomplete diagnostic clarity and undisclosed substance use (cann…

psychiatrycommunicationdiagnosticquetiapine
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
VIChome2022-03-31

Finding into death of Tessa Michelle Ballam

31y · Female·neck compression in the circumstances of hanging

Tessa Ballam, a 31-year-old accountant with longstanding depression, anxiety, bulimia nervosa, and borderline personality disorder (BPD), died by hanging in August 2015. She had experienced workplace difficulties with he…

psychiatrypsychologycommunicationsystemalcohol
TAShome2018-11-16

Coroner's Finding: Taylor, Michael John

50y · Male·methadone and alprazolam intoxication

Michael John Taylor, aged 50, died from methadone and alprazolam intoxication on 13 May 2016. He had chronic back pain and had been prescribed methadone and oxazepam since 2005. Evidence suggests he was crushing and inje…

general practicepain medicinecommunicationsystemmethadone
NSWmental health2025-10-20

Inquest into the Death of JSZ

66y · Male·Multiple blunt force injuries

JSZ, a 66-year-old forensic patient with chronic paranoid schizophrenia, died by suicide while on unsupervised day leave from Cumberland Hospital's Bunya Unit on 20 September 2023. He jumped from a cliff at Queen Elizabe…

psychiatryproceduralcommunicationzyprexa relprevv
WA- 12 September 2014

Inquest into the Death of Peter Philip HUMES

38y · Male·Ligature compression of the neck (hanging)

…lty settling, not for depression. Humes appeared to manage well during his stay, with no outward signs of suicidality detected by staff or prisoners until his death. The critical clinical lesson relates to cell design: h…

general practicecorrectional healthsystemdelaymirtazapine
TAScommunity2023-05-19

Coroner's Finding: Kirkwood, Jordan Thomas

19y · Male·hypoxic brain injury following asphyxia due to hanging

Jordan Kirkwood, a 19-year-old male, died by hanging on 30 April 2019 after being admitted to a newly established community-based mental health program (MHHITH) on 3 April 2019. He presented with depression, cannabis wit…

psychiatryemergency medicinediagnosticcommunicationfluoxetine
VICmental health2013-06-18

Finding into death of Paul Allan Skinner

29y · Male·hanging

Paul Skinner, a 29-year-old with depression and recent suicide attempt, was admitted to a psychiatric inpatient unit on involuntary status. Despite being prescribed 15-minute observations by his treating psychiatrist, nu…

psychiatrycommunicationsystem
WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.