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NSWmental health2019-10-25

Inquest into the death of T V

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…

psychiatrycardiologyhaloperidol
VIChome2019-10-10

Finding into death of Liana Pickup

32y · Female·Mixed drug toxicity (methadone, oxycodone, desmethylvenlafaxine, quetiapine, ola…

Liana Pickup, a 32-year-old woman with complex mental illness (bipolar disorder, borderline personality disorder, schizoaffective disorder), chronic back pain, and substance dependence, died from mixed drug toxicity afte…

general practicepsychiatrymedicationcommunicationmethadone
ACThome2019-09-20

Inquest into death of Kurt Mellick Andriske

52y · Male·septicaemia caused by Streptococcus Milleri group pneumonia

Kurt Mellick Andriske, 52, died from septicaemia caused by Streptococcus Milleri pneumonia, with drug toxicity as a contributing factor. He was a complex patient with bipolar disorder, chronic pain, hepatitis B and C, an…

general practicepsychiatrydiazepam
WAmental health2019-05-22

Inquest into the Death of Christopher John DEBNAM

40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…

Christopher John Debnam, 40, died from cardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensat…

psychiatryrespiratory medicinediagnosticcommunicationhaloperidol
SAhospital2019-05-08

Coroner's Finding: JONES Melissa Irene

45y · Female·methicillin resistant staphylococcus aureus (MRSA) endocarditis of the mitral va…

A 45-year-old woman with chronic renal failure requiring dialysis and bipolar disorder died of MRSA endocarditis of the mitral valve. She was detained under a Mental Health Act order due to manic episodes and non-complia…

nephrologypsychiatrylithium
TAShospital2019-02-22

Coroner's Finding: Mansfield, Doreen

78y · Female·Complications arising from a left femur fracture following an unwitnessed fall i…

Doreen Mansfield, a 78-year-old woman with bipolar affective disorder managed with lithium and ECT, was admitted to the Royal Hobart Hospital under a Mental Health Act treatment order. She sustained an unwitnessed fall i…

psychiatryorthopaedic surgerysystemlithium
VIChome2018-07-17

Finding into death of Mr L

45y · Male·Combined effects of plastic bag asphyxia and helium gas inhalation

A 45-year-old man with a history of bipolar affective disorder and previous suicide attempts died by combined plastic bag asphyxia and helium gas inhalation. He hired a helium cylinder from a party supply store on 2 Octo…

psychiatrygeneral practicesystemdiazepam
VICmental health2018-04-18

Finding into death of Gerard Helliar

62y · Male·Cerebral ischaemic injury due to hanging

Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…

psychiatryanaesthesiadiagnosticcommunicationsodium valproate
SAhospital2018-03-05

Coroner's Finding: HOWARD Miranda Robyn and MCPHERSON-SMITH Aurora Holly Violet

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…

psychiatrypsychologydiagnosticcommunicationquetiapine
QLDcommunity2017-08-17

JJKD - Non-inquest findings

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…

psychiatrycommunicationsystemclozapine
QLDaged care2017-06-09

DR - Non-inquest findings

46y · Female·Dilated cardiomyopathy (acute complication with sudden cardiac arrhythmia)

A 46-year-old woman with bipolar/schizoaffective disorder, poorly controlled type 2 diabetes, morbid obesity, severe obstructive sleep apnoea, and pulmonary hypertension died from acute dilated cardiomyopathy with sudden…

general medicineemergency medicinecommunicationsystemquetiapine
VICmental health2017-05-18

Finding into death of Derek Hamilton

46y · Male·Cerebral ischaemia secondary to compression of the neck in circumstances of hang…

Derek Hamilton, a 46-year-old involuntary psychiatric patient with cluster B personality disorder and recurrent depression, died from cerebral ischaemia secondary to hanging while an inpatient at Northern Hospital Psychi…

psychiatryintensive caresystemcommunicationmirtazapine
VICcommunity2017-03-30

Finding into death of HJE

33y · Female·Hanging

A 33-year-old woman with a history of depression, anxiety, and personality difficulties died by hanging on 14 February 2014, two days after separating from her partner. She had been under the care of a psychiatrist, Dr M…

psychiatrypsychologycommunicationquetiapine
NSWmental health2017-02-28

Inquest into the death of RC

53y · Male·Gunshot wound to the head

RC, a 53-year-old man with longstanding depression, died by suicide on 15 April 2014. He was under care of Campbelltown Community Mental Health (CoMHET) when a critical clinical failure occurred: a handwritten progress n…

psychiatrypsychologycommunicationsystemlithium
VICcommunity2017-02-20

Finding into death of Finding Peter Graham Chaucer

48y · Male·Injuries sustained when struck by a train

A 48-year-old man with mental health issues including depression and possible bipolar disorder died by suicide following train strike. He had a complex presentation with diagnostic uncertainty between bipolar affective d…

psychiatryemergency medicinecommunicationsystemlithium
VIChospital2016-08-19

Finding into death of Margaret Smith

91y · Female·Unascertained

Margaret Smith, a 91-year-old admitted with head strike from fall, developed moderate depression during her stay and received electroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigas…

psychiatrygeriatric medicinediagnosticdelaylithium
QLDhospital2016-06-20

Bradshaw, Scott Anthony - Non-inquest findings

38y · Male·Pulmonary thromboembolism due to bilateral deep calf vein thrombi

A 38-year-old man with schizo-affective disorder, bipolar disorder, and asthma presented to the emergency department with presumed pneumonia based on fever, pleuritic chest pain, and respiratory symptoms. His general pra…

emergency medicineintensive carediagnosticcommunicationhypnodorm
VIChome2016-03-11

Finding into death of AS

68y · Male·Gunshot injuries to the abdomen

A 68-year-old man with bipolar disorder and alcohol excess died by self-inflicted gunshot wound. He held a current firearms licence despite a documented history of psychiatric illness and problematic alcohol use. In his …

psychiatrygeneral practicecommunicationsystemlithium
NSWmental health2016-02-05

Inquest into the death of SS

48y · Male·hanging, intentionally self-inflicted

SS, a 48-year-old male with treatment-resistant depression and chronic suicidal ideation, died by hanging in Boronia Park, NSW in June 2014. He was admitted to Gosford Hospital Mental Health Unit in late May 2014 as an i…

psychiatrycommunicationsystemlithium
SAhospital2015-09-22

Coroner's Finding: WHETTERS Peter Richard Bertram

75y · Male·Multiorgan failure complicating mixed drug toxicity

A 75-year-old man with end-stage cardiac failure and chronic renal failure died from multiorgan failure complicating mixed drug toxicity following intentional overdose of alcohol, temazepam, and oxycodone. He had express…

cardiologyintensive caretemazepam

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