114 results
53y · Female·unascertained natural causes
Ms Rona, a 53-year-old woman with major depression, was admitted involuntarily to Bungarabee House psychiatric unit on 6 August 2018 after presenting with catatonic features, mutism, and refusal to eat or drink. She was …
25y · Male·Multiple system failure and ingestion of sodium nitrite
BT, a 25-year-old man with bipolar affective disorder and long-standing depression, died from intentional sodium nitrite ingestion while an inpatient in the Behavioural Assessment Unit at Royal Melbourne Hospital. He pre…
29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…
A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…
67y · Male·Head injuries sustained from a fall from the upstairs landing in Goldsmith G Blo…
Ye Chiu, a 67-year-old Chinese-speaking prisoner on remand, died by suicide in prison on 6 February 2017 after falling head-first from a landing. He had a complex psychiatric history including anxiety, depression, hypona…
47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)
Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
44y · Male·Cardiac arrhythmia during physical restraint
Taare Rangi, a 44-year-old man with bipolar affective disorder, died from cardiac arrhythmia during physical restraint in a mental health unit. Critical failures occurred at multiple levels: (1) the decision to acutely s…
46y · Female·Combined drug toxicity in a woman found in a bath
A 46-year-old woman with borderline personality disorder and bipolar affective disorder type 2 died from combined drug toxicity. She had a long history of overdose attempts, often without clear suicidal intent, and was u…
14y · Female·electrocution
Heidi Singh was a 14-year-old Aboriginal girl who died by electrocution at a railway pylon on 21 August 2014. She had suffered from foetal alcohol spectrum disorder since early childhood, experienced multiple losses (par…
22y · Male·Multiple injuries from fall from height
Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…
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…
30y · Male·ligature compression of the neck (hanging)
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…
52y · Female·Plastic bag asphyxia and asphyxia in the setting of an irrespirable environment
Diane Bell, a 53-year-old woman with delusional disorder and chronic suicidal ideation, died by argon gas inhalation in June 2017. She had been under care of North West Area Mental Health Service with a Community Treatme…
43y · Male·neck compression due to hanging
Michael David Bird, aged 43, died by hanging at his home while on home detention bail. He had a history of anxiety, depression, and chronic pain, managed by a psychiatrist (Dr T.) with weekly appointments described as hi…
36y · Male·Combined effect of gunshot wounds to the chest and abdomen
Paul Lambert, 36, was shot by NSW Police on the Pacific Highway after attacking and stabbing his former girlfriend Dr J. multiple times. He had a longstanding pattern of intimate partner violence, stalking, emotional abu…
55y · Male·positional asphyxia, with sedation as an underlying risk factor
Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg…
45y · Male·Cardiorespiratory arrest due to coronary artery disease, severe psychosis requir…
Stanley King, a 45-year-old man with severe psychosis, coronary artery disease, and obesity, died from cardiorespiratory arrest triggered by antipsychotic-induced laryngeal dystonia. Admitted involuntarily for acute psyc…
36y · Male·undetermined (possibly ethylene glycol poisoning; possibly natural cause such as…
A 36-year-old man with acute psychotic illness absconded from Ryde Hospital Emergency Department on 3 August 2013 after refusing oral antipsychotic medication. He evaded police efforts to locate him and was found dead in…
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·plastic bag asphyxia, possibly contributed to by neck compression
A 22-year-old woman with severe depression and documented suicidal ideation died by plastic bag asphyxiation while detained under a Mental Health Act order in a psychiatric ward. She had explicitly stated plastic bag asp…
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