997 results
24y · Male·hanging
Alexander Varcoe, a 24-year-old Aboriginal man, died by hanging in Yatala Labour Prison while on remand awaiting trial for serious charges. He had a complex history including prior self-harm in 1995-96, alleged prison ra…
28y · Male·Ligature compression of the neck (hanging)
Evan Charles Slater, 28, died by ligature compression of the neck (hanging) in Cell D7, Unit 10 of Hakea Prison on 12 March 2001. He was on remand facing assault and restraining order breach charges stemming from domesti…
29y · Male·Hanging
Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…
77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)
A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …
21y · Male·Cardiorespiratory arrest associated with butane abuse by inhalation
A 21-year-old detained psychiatric patient died from cardiorespiratory arrest following deliberate butane inhalation in a hospital wardrobe. He was admitted to an open mental health ward following acute psychosis, with d…
43y · Female·neck compression due to hanging
A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…
29y · Male·inhalation of petrol (hydrocarbon inhalation) causing respiratory depression wit…
Three Aboriginal men aged 25-29 years died from petrol inhalation in identical circumstances over 1999-2001, each found face-down in bed with a shaped petrol can sealed to their face. All were chronic sniffers (>10 years…
34y · Female·Dothiepin toxicity in a setting of post-natal depression
Debra Smeeton, 34, died on 12 November 1999 from dothiepin toxicity following intentional overdose at home, eight days after giving birth. She had severe post-natal depression after her first child in 1996, requiring hos…
Female·Dothiepin toxicity
Yvonne Carrigg, a woman with recurrent post-natal depression, died from dothiepin overdose three days after psychiatric discharge. Critical clinical failures included: prescribing dothiepin (a cardiotoxic tricyclic antid…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
43y · Male·Hypoxic/ischaemic encephalopathy resulting from asystolic cardiac arrest due to …
Gregory David Couper, 43, with chronic schizophrenia, experienced a psychiatric crisis at a supported residential care facility on 2 December 1998 and died the next day from restraint asphyxia. Police responded to calls …
26y · Male·Ligature compression of the neck (Hanging)
Scott Davidson, a 26-year-old recently sentenced prisoner with paranoid schizophrenia, died by suicide in Casuarina Prison on 5 June 2000. Following sentencing to 9 years imprisonment, he was transferred to Casuarina Pri…
34y · Male·neck compression due to hanging
A 34-year-old man with longstanding psychiatric illness died by hanging four days after discharge from psychiatric hospital. He had been admitted twice in August-September 1999 with active suicidal ideation and homicidal…
24y · Male·Aspiration of vomit associated with combined drug effect
Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…
15y · Male·compression of the neck by hanging
A 15-year-old Aboriginal male, Johnno Wurramarrba, from Groote Eylandt died by hanging in Don Dale Juvenile Detention Centre on 10 February 2000, while serving a 28-day sentence for property offences. Key preventable fac…
35y · Male·neck compression from hanging
A 35-year-old man with a history of depression, substance abuse, and acquired brain injury from assault was admitted to a psychiatric ward after self-harm with suicidal ideation. He was detained under the Mental Health A…
25y · Male·multiple injuries sustained in aircraft crash
Bryan G (Abel Dallos), a 25-year-old man with longstanding paranoid schizophrenia and treatment resistance, died in an aircraft crash after stealing an unlocked Piper Warrior from Alice Springs Airport and attempting to …
71y · Male·Saddle pulmonary embolus as a consequence of deep venous thrombosis in the right…
Glen Malcolm Klose, aged 71, died from a saddle pulmonary embolus secondary to deep vein thrombosis in his right calf, a complication associated with his history of multiple knee surgeries. He was admitted to Glenside Ho…
33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes
A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…
26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)
A 26-year-old man with schizophrenia, antisocial personality disorder, and polysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff…
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