Coronial

21 results for undiagnosed mental health condition

VIChome2022-04-07

Finding into death of Mr B

75y · Male·Effects of fire

…ture, then set their house on fire resulting in his own death. Evidence indicates Mr B was experiencing undiagnosed mental health conditions, mood swings, and manic behaviour. The couple faced multiple stressors includi…

general practicegastroenterology
VIChome2022-04-07

Finding into death of Mrs A

77y · Female·Neck compression in the setting of blunt force trauma to the head

…e experiencing relationship stressors including potential separation, financial disputes, Mr B's declining health, and COVID-related isolation. Mr B appeared to have an undiagnosed mental health condition with documented…

VICcommunity2015-10-06

Finding into death of Gregory Anderson

54y · Male·gunshot wound to the chest

…e, and consistent with Victoria Police training and protocols. The coroner noted Anderson likely had an undiagnosed delusional disorder and commented on systemic failures to engage him in mental health care despite prio…

psychiatryforensic medicinediagnosticsystemdiazepam
NSWcommunity2020-07-17

Inquest into the disappearance and suspected death of Max DAY

53y · Male·unknown - no postmortem examination possible

…25 January 2017. He had experienced a domestic violence incident on 6 January 2017, was detained under the Mental Health Act but assessed as not at immediate risk of self-harm, and subsequently left home with minimal bel…

psychiatryemergency medicine
NSW2017-11-16

Inquest into the death of Garry Weigand

56y · Male·fatal cardiac arrhythmia due to complications from acute bronchopneumonia and ar…

…ter arrest. He died from a fatal cardiac arrhythmia resulting from acute bronchopneumonia combined with undiagnosed arrhythmogenic right ventricular dysplasia (ARVD). Heavy alcohol use prior to custody had suppressed hi…

respiratory medicinepsychiatrymetoclopramide
SAhospital2021-06-30

Coroner's Finding: MAZMANIDIS Kiriakos Jack

83y · Male·respiratory failure due to chronic obstructive lung disease

…ction. He was appropriately managed with non-invasive ventilation, antibiotics, and antipsychotics under a Mental Health Act order. Despite treatment, his condition deteriorated due to advanced airway disease unresponsiv…

respiratory medicineintensive carehaloperidol
SAhospital2014-11-28

Coroner's Finding: HOGAN Constance Mary

73y · Female·general inanition due to dysphagia on a background of multiple neurological and …

…resented with stroke-like symptoms in March 2012. Neuroimaging was unrevealing. She was detained under the Mental Health Act due to concerns about oral intake and anticipated non-cooperation with treatment. Despite appro…

neurologypsychiatry
TAS2015-10-01

Coroner's Finding: Adamson, Darryl

49y · Male·traumatic amputation of right lower leg due to being trapped under a moving trac…

Darryl Arthur Adamson, a 49-year-old man with a history of seizures (within 3 days of death), severe ischaemic heart disease (70% LAD narrowing), and recent hepatitis C diagnosis, died from traumatic amputation of his ri…

cannabis
WAcommunity2018-09-20

Inquest into the Death of Scott Andrew BLANCHARD

45y · Male·Gunshot injury to the chest (self-inflicted)

… wound while on duty near Kalgoorlie. In June 2015, following a trip to Thailand, he developed anxiety and health concerns related to an undiagnosed medical condition despite negative investigations. He declined medicati…

psychiatryemergency medicinecommunication
NSWhome2016-07-19

Inquest into the deaths of Benjamin Green and William Markee

32y · Male·Gunshot wound to the head (Benjamin Green: homicide by William Markee; William M…

…abel, NSW. Markee shot Green in his sleep, then shot himself. Clinical lesson: Markee had clear, untreated mental health issues characterised by paranoid delusions, obsessive fixation, and suicidal ideation, but never en…

psychiatrygeneral practicedelay
TAShome2025-08-05

Coroner's Finding: Iliev, Patricia

57y · Female·starvation due to insufficient food intake

…liev retained decision-making capacity in her final days. Key clinical lessons: untreated chronic pain and mental health conditions can lead to fatal outcomes; patients with capacity must have documented advance directiv…

general practicepsychiatrysystemdelayaspirin
VICcommunity2022-08-01

Finding into death of X Y

53y · Male·Multiple gunshot injuries

…ife and stopped on the Monash Freeway. Police negotiated briefly before attempting a hands-on arrest under Mental Health Act s351. Man produced knife, beanbag rounds failed to incapacitate, he charged at officer with rai…

psychiatryemergency medicinecommunicationsystem
WA2024-05-08

Inquest into the Death of Michael John BIRD

22y · Male·Multiple injuries from fall from 21st floor balcony

…ry hallucinations and paranoid delusions about police surveillance for several months, likely due to an undiagnosed psychiatric condition. He disclosed these symptoms to a psychologist on 15 March but not to his GPs. Hi…

general practicepsychiatrycommunicationsystemzolpidem
NSWcommunity2010-10-15

Coroner's Finding: Charmaine Margaret Dragun

29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…

…ed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health professionals. The coroner found that Charmaine probably had undiagnosed Bipolar II Disorder—a condition 5…

general practicepsychiatrydiagnosticmedicationsertraline
TAShome2025-08-22

Coroner's Finding: Marshall, Benjamin Laurence

31y · Male·asphyxia due to self-inflicted hanging

… discharge from the Royal Australian Navy. He suffered from Bipolar Affective Disorder (BPAD), a genetic condition not causally related to his naval service, though initially misdiagnosed while serving. Key clinical les…

psychiatrypsychologysystemdiagnosticalcohol
VIC2015-02-23

Finding into death of Michael Theodore Anthony

28y · Male·toxicity to heroin

Michael Anthony, aged 28, died from heroin toxicity in a locked toilet cubicle at the Braybrook Hotel on 8-9 March 2011. He had a 13-year history of heroin dependence, complicated by polysubstance use including methylamp…

emergency medicineforensic medicinesystemdelayheroin
QLD2025-10-15

Inquest into the passing of ATJ

43y · Male·Hanging

…r covered by bedding would have been difficult. The death highlights the challenge of identifying emerging mental health concerns in custodial settings when critical observations are made only by cellmates and not formal…

psychiatrypsychologycommunicationsystemamitriptyline
VICcommunity2025-12-04

Finding into death of Mr PNF

60y · Male·Neck compression secondary to hanging

…nd relied on demeanor to conclude he was 'not at risk'—despite him expressing reputational concerns. His condition deteriorated significantly after release from custody. The coroner found police actions fell short of pr…

general practicepsychiatrycommunicationsystemfluoxetine
VIChospital2025-07-30

Finding into death of YTR

78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…

A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and …

geriatric medicineintensive caredelaysystemasenapine
QLDmental health2015-06-10

McDonnell, Kevin Joseph John

80y · Male·Drowning

…entional suicide. The death was likely due to accidental drowning in confusion, possibly complicated by undiagnosed cardiac disease.

psychiatryemergency medicinedocumentationcommunicationolanzapine

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