997 results
62y · Male·drowning
James Lee Osborn, aged 62, died by drowning in the Derwent River on 30 June 2016 after a rapid deterioration in mental health. He had a long history of depression but experienced acute decompensation with paranoid delusi…
28y · Female·aspiration of gastric contents complicating laxative abuse
A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
33y · Female·hanging, self-inflicted with intention of taking her own life
Naomi Watson Ley, a 33-year-old woman with a history of depression and borderline personality disorder, was admitted to Royal North Shore Hospital following suicidal ideation after medication changes (moclobemide to cita…
17y · Female·Hanging
Tahlia Peden, a 17-year-old Ngunnawal woman, died by hanging ten days after being sexually assaulted. She was assessed by Wagga Sexual Assault Service but a critical breakdown in the referral pathway meant Goulburn SAS n…
25y · Male·drowning
Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …
79y · Male·external neck compression as a result of hanging
A 79-year-old man with bipolar affective disorder and a documented history of medication non-compliance died by suicide while living in rural NSW. He had been subject to a Victorian Community Treatment Order (CTO) requir…
62y · Male·Cerebral ischaemic injury due to hanging
Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…
60y · Female·effects of fire in a woman with alcohol effect
A 60-year-old woman with chronic paranoid schizophrenia died in a domestic fire on 26 July 2014. The day before, her son sought help from police and mental health services after noticing signs of mental health deteriorat…
31y · Male·bronchopneumonia and hypoxic brain injury following ligature compression of the …
31-year-old Moses Sokiri died on 26 October 2014 from bronchopneumonia and hypoxic brain injury following suicide by hanging at Greenwood train station on 12 October 2014. The deceased was in acute mental health crisis w…
25y · Female·mixed drug toxicity
Lauren Elizabeth Bunn, aged 25, died by voluntary ingestion of mixed drugs in October 2016. She had a longstanding history of serious mental illness with multiple documented suicide attempts and police welfare checks in …
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
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…
53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging
Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…
21y · Male·asphyxia from inhalation of helium
21-year-old Devlin Duffy died from asphyxia due to helium inhalation. He had connective tissue disease causing chronic pain and disability. In May 2016, his GP Dr N. diagnosed moderate depression and prescribed desvenlaf…
45y · Male·Stab wound to the chest, self-inflicted
Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge from psychiatric hospital on a Community Treatment Order. He was dis…
36y · Male·Hanging
A 36-year-old man with schizoaffective disorder, substance use disorder, and previous psychotic episodes was discharged from psychiatric inpatient care after being absent without leave for 72 hours. On 4 June 2017, he co…
49y · Female·Bronchopneumonia, hypoxic brain injury, and combined drug toxicity (oxycodone an…
Karen Moore, aged 49, died from bronchopneumonia following hypoxic brain injury caused by combined drug toxicity (oxycodone and diazepam). She was found unconscious at home after an overdose and did not regain consciousn…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…
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