81 results
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…
64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…
Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
26y · Male·Coronary artery atherosclerosis in the setting of schizoaffective disorder
Matthew Howarth, 26 years old with schizoaffective disorder, died of coronary artery atherosclerosis while an inpatient at a mental health secure care facility. He was involuntarily admitted on 16 November 2022 with psyc…
38y · Male·electrical injury
Benjamin Van Trigt, a 38-year-old man with schizoaffective disorder, died by electrocution at home on 17 November 2022 while on a Community Treatment Order (CTO). He had experienced multiple psychiatric relapses requirin…
22y · Unknown·sudden death associated with volatile substance inhalation (butane and propane)
A 22-year-old Yolngu person with a well-documented history of volatile substance abuse (VSA) and mental illness was involuntarily admitted to Royal Darwin Hospital for acute psychosis. Due to COVID-19 bed-block, they wer…
53y · Male·Cardiomegaly in a man with obesity and chronic liver disease
Craig Ashley Hill, a 53-year-old man with multiple comorbidities including obesity, chronic liver disease with cirrhosis, cardiomegaly, hypertension, diabetes, and mental health conditions, died suddenly in hospital from…
26y · Male·Craniocervical injuries following a train collision (pedestrian)
Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
28y · Female·Multiple injuries sustained in a fall from height
Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…
41y · Male·undetermined
Vaughan Weston Williamson, 41, died at Glenside Hospital while subject to a Level 3 Inpatient Treatment Order for treatment-resistant schizophrenia. Despite post-mortem examination including specialist neuropathological …
47y · Male·combined acute effects of multiple drugs in obese man with enlarged heart and ar…
Nicholas Cripps, a 47-year-old man with treatment-resistant schizophrenia, substance use disorder, and antisocial personality disorder, died from combined acute effects of multiple drugs (methylamphetamine, quetiapine, p…
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
40y · Female·Complications of WHO Class III Obesity
Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac complications seven days after psychiatric admission. …
51y · Male·Stab wound to the heart
Brian Liston, a 51-year-old teacher, died from a stab wound to the heart inflicted by William Cahill during an unprovoked attack at a bus stop in December 2015. Cahill suffers severe treatment-resistant schizophrenia and…
26y · Male·Mixed drug toxicity (heroin, morphine, codeine combined with lorazepam, olanzapi…
Nicholas Lopes, a 26-year-old with treatment-resistant schizophrenia, intellectual disability, and substance use disorders, died from mixed drug toxicity (heroin combined with benzodiazepines and antipsychotics) two days…
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