212 results
50y · Male·Mixed drug toxicity (propofol, codeine, diazepam)
Mark Wilson, a 50-year-old registered nurse at The Avenue Private Hospital, died from mixed drug toxicity involving propofol, codeine, and diazepam. He had access to propofol through his workplace and was found dead at h…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…
A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…
31y · Female·plastic bag asphyxia
Kirstan McRae-Jansen, a 31-year-old woman with chronic schizophrenia, borderline personality disorder, and substance abuse, died by plastic bag asphyxia using an LPG bottle. She was under Community Treatment Order with E…
31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…
Georgia Cheal, a 31-year-old with complex medical history including chronic pain, major depression, and obesity, died from pneumonia exacerbated by combined drug toxicity from multiple prescription medications, cannabis,…
24y · Female·hanging
A 24-year-old woman with longstanding depression, anxiety, and a history of self-harm and suicidal ideation died by hanging following a marital conflict. She had been under care of university counsellors and a psychologi…
27y · Male·Multiple injuries sustained when struck by a train
A 27-year-old man with a history of anxiety disorder and depression died by suicide, placing himself in front of a train. He had presented to emergency with suicidal ideation and overdose one week prior and was assessed …
39y · Female·hanging
Kate Miller, 39, died by hanging at The Melbourne Clinic on 11 October 2011. She had severe borderline personality disorder with recurrent high-lethality suicide attempts and chronic self-harm urges. A shared care arrang…
58y · Male·Unascertained causes
A 58-year-old man with treatment-resistant schizophrenia living in aged care died suddenly 30 minutes after receiving his evening clozapine dose. Although post-mortem toxicology detected a potentially toxic clozapine lev…
43y · Male·Hanging
Brett Andrew Pollini, a 43-year-old fire station officer with bipolar affective disorder, died by suicide following a distressing telephone call with the Child Support Agency (CSA) regarding a substantial increase in chi…
79y · Female·pneumonia in the setting of acute peritonitis due to perforated stomach (operate…
Mrs Thelma Katherine Holt, a 79-year-old woman with multiple comorbidities including obesity, vascular disease, hypertension, and prior Nissen fundoplication, underwent placement of a second intragastric balloon on 11 Se…
37y · Male·Toxic effects of heroin in combination with mirtazapine and sertraline
Leigh Ronald Bellingham, a 37-year-old man with a history of depression, suicidality, hepatitis C, and substance abuse, died from toxic effects of heroin in combination with mirtazapine and sertraline in June 2008. He wa…
31y · Male·Quetiapine toxicity in a man consuming sertraline and mirtazapine
31-year-old with bipolar disorder died from quetiapine toxicity while taking sertraline and mirtazapine. He was under a Community Treatment Order and his treating team reduced his antipsychotic dose while he deteriorated…
45y · Male·exsanguination due to incised wound to neck
Lawrence McCarty, a 45-year-old man in custody on remand, died by suicide in prison on 30 April 2011 by slashing his neck with a dismantled razor blade. Clinical lessons include: (1) reception staff failed to adequately …
31y · Male·Chest injuries (principal cause) with autism and epilepsy as underlying causes
Stuart Lambert, a 31-year-old man with cerebral palsy, autism, and epilepsy, died from chest injuries sustained at his carer's semi-rural residence. He collapsed during or after a seizure and experienced multiple rib fra…
55y · Male·Immersion
Peter Fisher, a 55-year-old man with schizophrenia and depression, died from immersion after becoming homeless. Discharged from The Alfred Hospital in February 2007 to supported accommodation without a Community Treatmen…
30y · Male·asphyxia due to hanging (suicide)
30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…
69y · Female·bronchopneumonia complicating intracranial tumour (meningioma with obstructive h…
Mary Patricia Kruger, aged 69, died of bronchopneumonia complicating a massive subfrontal meningioma with obstructive hydrocephalus. Her death was preventable. During a November 2006 hospital admission for urinary tract …
55y · Male·Morphine toxicity, with contributing factors of ischemic heart disease, coronary…
Shane Paul Krog, a 55-year-old man, died from morphine toxicity complicated by ischemic heart disease, coronary atherosclerosis and rhabdomyolysis. He presented to Murgon Hospital (a 15-bed rural facility) following susp…
74y · Female·right lower lobe pneumonia (Staphylococcus aureus)
A 74-year-old woman admitted for depression and functional decline following aortic valve replacement received 15mg Nitrazepam instead of prescribed 15mg Mirtazapine due to drug name confusion. The sedation caused aspira…
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