Coronial — Australian Coroners Findings

State

WA1NSWVIC1QLDSATASACTNT

Setting

hospital1aged caremental health1communityhomeother

Hospital

Royal Melbourne Hospital1Merredin Hospital1

Specialty

psychiatry2geriatric medicine1emergency medicine1

Error Type

diagnostic1medicationproceduralcommunication1system2delay2

Preventability

PreventablePossibly preventable2Not preventableNot stated

Age Group

Adult2PaediatricNeonate

Sex

Male1Female1

Clinical Flags

Escalation failureAHPRA referral madeRural / remote1Prison / police custodyAged care deathMental Health Act involved1Family violence relatedHas recommendations2

Year Range

–

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VICmental health2017-06-29

Finding into death of Peter James Nolan

75y · Male·Hanging

Peter Nolan, a 75-year-old man with depression, chronic pain, alcohol dependence, and recent suicide attempts, died by hanging in an aged psychiatric mental health unit. He was admitted to Broadmeadows Aged Psychiatric M…

psychiatrygeriatric medicinesystemcommunicationsertraline

WAhospital2005-05

Inquest into the Death of Olivia ("Peta") Dawson

26y · Female·Asphyxiation due to Ligature Compression of Neck

Peta Dawson, a 26-year-old woman with a history of depression, self-harm, and suicidal ideation following miscarriage and maternal rejection, was admitted to Merredin Hospital on 10 August 2003 after presenting with wris…

emergency medicinepsychiatrysystemdelaykalma

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