63 results
51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…
Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…
48y · Female·Mixed drug toxicity (morphine, codeine, venlafaxine, amitriptyline and zopiclone…
A 48-year-old woman with depression, anxiety, and bipolar disorder died from mixed drug toxicity while on voluntary inpatient psychiatric admission. She had undisclosed significant illicit drug use, which was not identif…
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug toxicity. Postmortem toxicology revealed high-co…
23y · Female·unascertained
Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …
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 …
44y · Male·Multiple blunt force injuries from fall from height
Michael Murray, aged 44, died following a fall from Landslide Lookout in the Blue Mountains. He had been diagnosed with borderline personality disorder (BPD) and chronic suicidality. His death highlighted critical gaps i…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…
59y · Male·Massive aspiration in the setting of intubation following complications of sever…
A 59-year-old man with treatment-resistant schizophrenia on long-term clozapine therapy died from massive aspiration following a severe ileus of unknown aetiology. He had documented constipation managed with laxatives, t…
51y · Male·Hyperthermia of unknown cause in a man with cardiac hypertrophy; chronic obstruc…
Arthur Andrianakis, 51, died from hyperthermia of unknown cause with cardiac hypertrophy and COPD. He presented to hospital with respiratory distress following police custody for assaulting his mother. Initial diagnosis …
44y · Male·gunshot wound to the abdomen
Vlado Micetic, 44, was fatally shot by Leading Senior Constable Timothy Baker during a traffic interception for stolen number plates in Windsor, Victoria, on 25 August 2013. Baker claimed Micetic produced a knife during …
Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…
Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…
33y · Male·Gunshot injury to the anterior trunk (chest and upper abdomen)
Desmond Jack, a 33-year-old with longstanding bipolar affective disorder and psychotic symptoms, died from a single gunshot wound to the anterior trunk after being shot by police officer Senior Constable Harrison on 28 M…
65y · Female·choking on a tangerine
Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…
56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels
Julie-Anne Kettle, a 56-year-old woman with intellectual disabilities residing in a group home, died from bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric…
64y · Female·phosphine toxicity from deliberate ingestion of aluminium phosphide fumigation p…
Janice Croft, 64, died from phosphine toxicity after deliberately ingesting fumigation pellets during a police intervention on her property facing eviction for mortgage default. Ms Croft had long-standing bipolar disorde…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
54y · Female·combined drug toxicity (heroin, morphine, cannabis, and prescription medications…
Laureen Kaye Reilly, aged 54, died from combined drug toxicity involving heroin, cannabis, and prescription medications including antipsychotics and mood stabilizers. She had complex mental health disorders, acquired bra…
23y · Female·Arrhythmia of unknown aetiology
TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…
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