80 results
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
72y · Male·exsanguination (blood loss) from severed femoral artery
Stephen Maxwell Powell, a 72-year-old man with schizophrenia, died by exsanguination from a self-inflicted femoral artery laceration. He was discharged from psychiatric inpatient care on a community treatment order on 14…
24y · Male·self-inflicted hanging
Linden Alan Kunoth, a 24-year-old Aboriginal man, died by suicide while on escorted leave from psychiatric care. He had been admitted with first-episode schizophrenia, presenting with florid psychosis and command halluci…
38y · Male·ligature compression of the neck (hanging)
Mark Quenton Fleury, a 38-year-old man with paranoid schizophrenia, died by suicide on 14 February 2016 while subject to a Community Treatment Order. In the final week of his life, he presented to emergency services and …
30y · Male·methadone toxicity
A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging
Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…
42y · Male·Multiple injuries sustained in motor vehicle crash
A 42-year-old man with schizoaffective disorder subject to a Community Treatment Order died in a single-vehicle motor crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern…
34y · Male·drowning
A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and…
47y · Male·Multi organ failure and sepsis complicating ulcerating colitis and intestinal ob…
David Waymouth, a 47-year-old prisoner with extensive medical comorbidities including hepatitis C, obesity, chronic pain requiring methadone, and depression, fell from his bed in prison and sustained a right hip fracture…
37y · Male·Multiple injuries (motor vehicle impact – pedestrian)
Justin Connell, a 37-year-old man with schizophrenia, died from multiple injuries sustained in a pedestrian–motor vehicle collision on 13 February 2013. He had been diagnosed with schizophrenia in October 2012 and prescr…
83y · Female·right middle cerebral artery infarct/stroke
Mrs Arsho Balian, an 83-year-old woman with dementia, schizophrenia, diabetes and recurrent UTIs, suffered a right middle cerebral artery stroke while resident in aged care under a guardianship order. She was appropriate…
47y · Female·Pulmonary thromboembolism secondary to deep vein thrombosis
Fatima Lay, a 47-year-old woman with schizophrenia and developmental disability living in supported residential accommodation, died from pulmonary thromboembolism secondary to deep vein thrombosis. She collapsed in the b…
29y · Male·Injuries sustained in a fall from a height
A 29-year-old man with chronic paranoid schizophrenia died from injuries sustained after jumping from the EJ Whitten Bridge. He had a 5-year history of psychiatric illness with recurrent psychotic episodes despite treatm…
47y · Male·pulmonary thromboembolism and deep vein thrombosis
Paul Finck, 47, an involuntary psychiatric patient with schizophrenia, died from pulmonary thromboembolism and deep vein thrombosis while admitted to the psychiatric ward. He presented with fever, tachycardia, elevated C…
52y · Male·consistent with plastic bag asphyxia
Frederick Williamson, a 52-year-old man with chronic treatment-refractory schizophrenia, was found dead in the bathroom of his room at Austin Health's Secure Extended Care Unit with a plastic bag over his head, consisten…
27y · Male·Hanging
Richard Hilton, a 27-year-old with longstanding bipolar affective disorder and benzodiazepine dependence, presented to Werribee ED three times in two months with suicidal ideation and self-harm attempts. Each time he was…
28y · Male·neck compression subsequent upon hanging
Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …
45y · Female·Complications of acute alcohol intoxication
Ruth Janet Younger, a 45-year-old woman with treatment-resistant schizophrenia subject to a Community Treatment Order, was discharged from Casey Hospital psychiatry ward on 1 June 2010 while anxious and paranoid. She abs…
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