114 results
34y · Male·hanging
John Sydney Farmer, aged 34, died by hanging at his home on 23 May 2008, six hours after being granted leave from psychiatric detention at Woodleigh House. He had attempted suicide by carbon monoxide poisoning two days e…
44y · Female·mixed drug toxicity with aspiration of gastric contents
A 44-year-old woman with chronic back pain and depression died from mixed drug toxicity with aspiration of gastric contents. She had been prescribed multiple medications including amitriptyline, diazepam, codeine, and lo…
35y · Female·pulmonary thrombo-emboli
A 35-year-old woman with treatment-resistant schizophrenia detained under Mental Health Act died from pulmonary thromboembolism while an inpatient in a psychiatric ward. In the final days, she reported leg pain and possi…
54y · Male·hanging by ligature
Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic open ward. He had expressed suicidal ideation throughout his adm…
49y · Male·hanging (suicide)
Antonio Rodriguez, aged 49, died by hanging on 16 September 2006, two hours after discharge from Ward B8 (psychiatric short-stay unit) at Royal Adelaide Hospital. He had been admitted with severe depression and active su…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
Michael Cockburn, a 40-year-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anae…
36y · Male·Multi-organ failure due to consequences of multiple injuries sustained following…
A 36-year-old man with chronic treatment-refractory paranoid schizophrenia was involuntarily detained in an acute psychiatric ward after a failed community trial. Despite being a documented high absconding risk, he was t…
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
Joint inquest into two homicides by individuals with schizophrenia who were managed by mental health services. Anthony Butler stabbed David Gerard in 2001 after being discharged from Glenside Hospital without Community T…
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and atropine obtained from a hospital …
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
Paul John Long, a 37-year-old man with chronic schizoaffective disorder and alcohol dependence, died on 4 November 2002 from acute aspiration pneumonitis following quetiapine overdose. After presenting to Avro Clinic in …
30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology
Giovanni Mario Franco, a 30-year-old man with schizophrenia, died on 10 March 1998 at Graylands Hospital from acute cardiac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed se…
28y · Female·multiple injuries
Sarah Jane Rutherford, a 28-year-old with bipolar affective disorder and schizophrenia, died by suicide on 27 December 2009 after falling from a bridge onto the Mitchell Freeway while on leave from Graylands Hospital. Sh…
56y · Female·Bronchial asthma and emphysema
A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…
24y · Male·complications of ligature compression of the neck (hanging)
Vincent Schwenke, a 24-year-old male of Maori descent, developed acute psychotic symptoms after ceasing cannabis use and was admitted to a secure mental health unit as an involuntary patient. Despite initial improvement …
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