139 results
27y · Male·Injuries sustained in descent from height
A 27-year-old man with schizophrenia was brought to Northern Hospital ED by police under Mental Health Act section 351 after threatening suicide and injecting testosterone. The Emergency Department doctor (Dr K.) assesse…
43y · Male·hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic …
Jay Alan Paterson, a 43-year-old man with chronic pain and opioid dependence, died from hypoxic-ischaemic encephalopathy following polypharmacy overdose and iatrogenic upper airway injury. He obtained 296 oxycodone table…
42y · Female·Incised injury to the neck
A 42-year-old woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Cli…
55y · Male·positional asphyxia, with sedation as an underlying risk factor
Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intravenous sedation (75mg…
54y · Male·Extensive burns due to detonation of LPG gas cylinder
A 54-year-old man with chronic severe depression, grief from his wife's sudden death, severe debilitating skin condition, and alcohol dependence called emergency services on 12 December 2015, warning them not to approach…
36y · Male·undetermined (possibly ethylene glycol poisoning; possibly natural cause such as…
A 36-year-old man with acute psychotic illness absconded from Ryde Hospital Emergency Department on 3 August 2013 after refusing oral antipsychotic medication. He evaded police efforts to locate him and was found dead in…
39y · Female·Hypovolaemic shock due to incised injury to the wrist
A 39-year-old woman with a history of mental health issues and previous suicide attempts was admitted to a high-dependency psychiatric unit following a suicide attempt involving razor blades and medications. She was plac…
28y · Male·Neck compression consistent with hanging
A 28-year-old man with severe depression, persistent suicidal ideation and previous suicide attempts died by hanging in a mental health inpatient unit while under involuntary detention. Despite being assessed as high sui…
45y · Male·The effects of restraint and drugs
Warren Osborne, a 45-year-old man affected by amphetamines and experiencing drug-induced psychosis, died during physical restraint at Caboolture Hospital. After being triaged in the Emergency Department, he accessed rest…
35y · Male·Fentanyl toxicity
David Veech, aged 35, died of accidental Fentanyl toxicity while residing at Tarlo Intensive Residential Support Service. He extracted Fentanyl from prescribed transdermal patches and injected it intravenously. Despite b…
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…
32y · Male·Multidrug overdose
A 32-year-old man with a history of polysubstance abuse, schizoaffective disorder, and chronic pain died from multidrug overdose at home. He had obtained fentanyl, clonazepam, diazepam, methadone, and other drugs from mu…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant failures in supervision an…
22y · Female·compression of the neck consistent with hanging
22-year-old Deborah McKenzie, an Aboriginal woman, died by hanging on 13 March 2013 after a complex sequence of failures in mental health care and police procedures. She had reported her partner Shane Woods to police for…
24y · Male·inhaled solvent toxicity (from petrol sniffing)
Edward James Laurie, a 24-year-old man with chronic petrol sniffing addiction since age 10 and underlying mental health issues including psychosis, died from inhaled solvent toxicity on 11 October 2015. Sixteen Applicati…
18y · Female·neck compression due to hanging
An 18-year-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate communication of previous s…
32y · Female·combined drug toxicity, mainly heroin
Natasha Calleja, 32 years old, died from combined drug toxicity (mainly heroin) while an involuntary inpatient at Swanston Centre psychiatric unit after her de facto partner supplied heroin during an unsupervised visit. …
50y · Female·Hanging
Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …
Miriam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during th…
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