12 results
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembolism on 12 March 2023 while under Mental Health Act care. After two weeks of increasingly challen…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
31y · Male·undetermined
Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…
49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
Phillip Veltman, 49, died of unascertained cause (likely cardiac arrhythmia with terminal aspiration) while an involuntary psychiatric patient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on…
24y · Male·Hypoxic brain injury secondary to hanging
BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He was admitted on 4 January 2016 with suicida…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
30y · Male·methadone toxicity
A 30-year-old man with schizoaffective disorder, narcolepsy, and obesity died from methadone toxicity while an involuntary psychiatric patient. He was prescribed multiple sedating medications including methadone, benzodi…
22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree
22-year-old Benjamin Gilligan died in a motor vehicle crash while fleeing psychiatric care, having been recently diagnosed with methylamphetamine-induced psychosis. Key clinical issues identified: (1) communication break…
43y · Male·Pneumonia
Jeffrey John Hartwig, a 43-year-old with chronic schizophrenia and opiate dependence, died from pneumonia following cardiorespiratory collapse on an acute psychiatric inpatient unit. He was on multiple psychoactive medic…
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
Frank Sette, a 72-year-old man with longstanding schizophrenia, died from a cranial fracture and intracranial haemorrhage sustained when he deliberately threw himself backwards onto the floor of a psychiatric ward. He wa…
52y · Female·Hypoxic brain injury due to hypotension in a woman with documented electrocardio…
Elizabeth Holley, 52 years old, was admitted involuntarily to a psychiatric ward with a history of three weeks of declining mental health and medication non-compliance. She received high-dose antipsychotic medications in…
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 …
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