398 results
30y · Male·neck compression
Mohamed Omar, a 30-year-old man with schizophrenia, died in Melbourne Assessment Prison on 25 June 2017 from neck compression while on remand. He had a history of command auditory hallucinations instructing self-harm, re…
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 …
70y · Male·Hanging
A 60-year-old man with recent pituitary surgery developed persistent fatigue and depressive symptoms. Despite normal cortisol levels, he remained convinced his symptoms were due to hormonal deficiency rather than depress…
53y · Male·Complications of old brain injury in prior motor vehicle incident
Bruce Vernon Taylor, 53, died from complications of a remote brain injury sustained in childhood motor vehicle accident. He lived in shared disability accommodation and received support through NDIS. In the 12 months bef…
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…
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…
36y · Female·combined effects of baclofen toxicity and blunt head injury
Kim Melissa Hall, 36, died from combined baclofen toxicity and blunt head injury sustained during falls while acutely intoxicated. She had severe alcohol dependence treated with off-label baclofen prescribed by her GP. O…
26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases
Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to …
68y · Male·Complications of retroperitoneal haemorrhage due to inadvertent administration o…
Ian Fraser, 68, died from retroperitoneal haemorrhage following inadvertent dual anticoagulation with apixaban and enoxaparin. On 29 November 2019, a respiratory registrar attempted to prescribe discharge apixaban but mi…
36y · Male·Combined drug toxicity (pregabalin, morphine, amitriptyline)
A 36-year-old motor mechanic with chronic pain from a 2014 knee injury died from combined drug toxicity (pregabalin, morphine, amitriptyline). His general practitioner, Dr S., prescribed excessive amounts of multiple med…
46y · Female·Hypoxic brain injury in the setting of plastic bag asphyxia
Michelle Williams, a 46-year-old woman with longstanding schizophrenia and depression, died from hypoxic brain injury due to plastic bag asphyxia while an involuntary inpatient in a psychiatric unit. On 27 August 2016, d…
38y · Male·asphyxiation by ligature
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotic…
47y · Male·organ failure following cardiorespiratory impairment in a man with arteriosclero…
Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate re…
49y · Male·incised injury to the neck
Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…
54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
A 54-year-old man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to…
44y · Male·intravenous injection of foreign debris (crushed tablets) associated with chroni…
Timothy Wellington, a 44-year-old man with longstanding opioid and polysubstance use disorder, died from acute pulmonary hypertension caused by intravenous injection of foreign debris (crushed tablets). He had been presc…
31y · Male·Acute Myocardial Infarction
John Pocklington, aged 31, died of acute myocardial infarction while in remand custody. He had a long history of methamphetamine use and untreated cardiac damage. On 28 April 2015, he reported chest pain to a nurse, who …
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…
70y · Female·end stage dementia
Carole Ann Dunstan, a 70-year-old woman with end-stage dementia, died of natural causes at Repatriation General Hospital on 17 June 2017 while subject to a Level 3 Inpatient Treatment Order. She had been admitted followi…
74y · Female·Multiple injuries sustained when struck by train
A 74-year-old woman with borderline personality disorder, depression, anxiety and type 2 diabetes died by suicide after absconding from Fiona Stanley Hospital Emergency Department. She had been on extended psychiatric ad…
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