398 results
36y · Male·Multi-organ failure complicating injecting drug use
A 36-year-old man with a 13-year history of schizophrenia and substance abuse was admitted involuntarily to a psychiatric unit on 15 September 2012 after community deterioration. He improved over several weeks and was tr…
38y · Male·metastatic poorly differentiated carcinoma on a background of delirium and schiz…
Anthony Sissons, aged 38, died of metastatic renal carcinoma while under a Mental Health Act inpatient treatment order. He presented to hospital on three separate occasions (13-15 June 2012) with constipation, which was …
28y · Male·Neck compression consistent with hanging
A 28-year-old man with severe depression, persistent suicidal ideation and previous suicide attempts died by hanging in a mental health inpatient unit while under involuntary detention. Despite being assessed as high sui…
59y · Female·Hypoxic ischaemic brain injury secondary to compression of the neck in the circu…
A 59-year-old woman with major depression died by hanging using her dressing gown tie while a voluntary inpatient at a private psychiatric clinic. She was assessed as low-risk and had no restriction on ligature access. D…
36y · Male·mixed drug toxicity
Justin Blade Stewart, a 36-year-old man with a long history of schizophrenia managed with antipsychotic medications, died from mixed drug toxicity. He was found deceased at home after sleeping overnight. Toxicology revea…
34y · Male·Hanging
Errol Handog, a 34-year-old man presenting with anxiety, was assessed by psychiatry on two consecutive days at Nepean Hospital and discharged to community care despite suicidal ideation. A key clinical lesson is that inc…
72y · Male·Bronchopneumonia in the setting of chronic aspiration in a man with mixed Alzhei…
A 72-year-old man with mixed Alzheimer's and alcohol-related dementia died of bronchopneumonia secondary to chronic aspiration in a psychogeriatric facility. He had severe ischaemic heart disease and prostate cancer. Des…
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…
35y · Male·Fentanyl toxicity
David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…
26y · Female·Toxicity to Pentobarbitone
Dannika Smith, aged 26, died from pentobarbitone toxicity after deliberate self-ingestion. She had Borderline Personality Disorder with documented suicidal ideation and had previously attempted suicide. She imported pent…
47y · Female·Sudden Unexpected Death in Alcohol Misuse (SUDAM)
Lesley Maree Smith, 47, died at home on 9 May 2013 from Sudden Unexpected Death in Alcohol Misuse (SUDAM). She had chronic alcohol misuse (2 bottles nightly) and was prescribed diazepam by her GP, Dr H., starting April 2…
63y · Male·Multiple injuries due to fall from height
A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…
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…
41y · Female·Left middle cerebral artery territory ischaemic stroke
A 41-year-old registered nurse presented to the Emergency Department with altered consciousness on 28 May 2015. She was initially assessed as having a possible medication overdose rather than acute stroke, despite later …
23y · Male·Unable to be determined from available evidence
Benjamin Stephens, aged 23, went missing on 18 March 2004 from rural NSW and was confirmed deceased in 2016 when his skull was discovered via DNA matching. In the months before his disappearance, Ben developed symptoms c…
68y · Female·Hypoxic Ischaemic Encephalopathy as a result of Hanging
A 68-year-old woman with longstanding psychotic illness presented to ED with acute relapse, homicidal ideation toward her husband, and vague suicidal threats. Psychiatry assessed suicide risk as low based on her denial o…
27y · Male·Mixed drug toxicity
A 27-year-old man with polysubstance abuse disorder, generalised anxiety disorder, and borderline personality disorder died from mixed drug toxicity (heroin, morphine, diazepam, citalopram, quetiapine) shortly after disc…
47y · Female·Multiple injuries from being struck by a train
A 47-year-old woman with major depressive disorder and anxiety died by suicide while an involuntary psychiatric inpatient. She had attempted suicide in November 2014 and was admitted to Bentley Hospital for psychiatric t…
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…
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