64 results
50y · Male·Gunshot wound to the head
A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…
67y · Male·Congestive cardiac failure
Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…
77y · Female·Complications of malnutrition in a woman with paranoid delusions
A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium. She was admitted following falls and required compulsory t…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
77y · Female·Airways obstruction by tissue paper
A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…
31y · Male·compression of the neck secondary to hanging
Rory Van Geleuken, a 31-year-old with longstanding major depressive disorder, generalised anxiety disorder, autism spectrum disorder, and ADHD, died by hanging. He had received mental health treatment since age 17, inclu…
43y · Male·Mixed drug toxicity (methadone, synthetic cannabinoids (5f-cumyl-pinaca and cumy…
Shayn Darmanin, a 43-year-old man with epilepsy, died from mixed drug toxicity involving methadone, synthetic cannabinoids, olanzapine, and duloxetine. He had a significant history of substance abuse, family violence off…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
Kim Bartolo, a 47-year-old woman with depression, anxiety, alcohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hos…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
53y · Male·Cervical spine distraction and hanging
A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with …
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
27y · Male·Multiple gunshot wounds
Damon Savage, 27, died from multiple gunshot wounds during a police response to a domestic violence incident. He had called police while assaulting his partner, armed himself with two large knives, advanced towards offic…
48y · Male·Gunshot wound to the chest during a police operation
Corey Selby, aged 48, died from a gunshot wound to the chest on 19 January 2023 outside Tenterfield Police Station after deliberately provoking police to shoot him. He had a complex mental health presentation comprising …
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
40y · Female·ligature compression of the neck (hanging)
Petra Michelle Marquis, a 40-year-old woman with a documented history of mental health issues including depression, anxiety, PTSD, and borderline personality disorder, died by suicide while in police custody after being …
52y · Male·fully suspended hanging
A 52-year-old man died by fully suspended hanging following a series of acute stressors. He had a history of ischemic heart disease and was on antidepressant medication. A critical precipitant was an early morning AFP se…
68y · Male·Multi-organ failure due to gram-negative sepsis on a background of recent myocar…
A 68-year-old male prisoner with multiple comorbidities (diabetes, end-stage renal failure, COPD, morbid obesity) presented with acute myocardial infarction and underwent coronary artery bypass grafting. Post-operatively…
37y · Male·mixed drug toxicity with fentanyl as the principal agent
37-year-old Jason Cullen died from mixed drug toxicity with fentanyl as the principal agent. He had chronic idiopathic intracranial hypertension requiring multiple neurosurgeries and was prescribed opioids and benzodiaze…
33y · Female·Mixed drug toxicity (propranolol, oxycodone, diazepam, temazepam, lurasidone, du…
Melissa Arbuckle, a 33-year-old woman, died from mixed drug toxicity (propranolol, oxycodone, diazepam, temazepam, lurasidone, duloxetine) by intentional overdose. She had been convicted of infanticide following her daug…
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