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NSWaged care2012-05-11

Inquest into the deaths of Shaneen BATTS, Ilona TAKACS, Dorothy HUDSON, Ian BIRKS, Donald MacKELLAR and Mohammed RAMZAN

Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …

This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…

psychiatrygeneral practicediagnosticmedicationolanzapine
SAhome2012-05-09

Coroner's Finding: PENNIALL David

24y · Male·neck compression due to hanging

A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…

psychiatrygeneral practicecommunicationdelayvenlafaxine
VICmental health2012-04-30

Finding into death of Travis Andrew McNees

18y · Male·Multiple injuries due to impact by train

Travis McNees, 18-year-old male, died by suicide on 4 October 2010 after absconding from Upton House psychiatric unit. He presented to ED on 29 September with paracetamol/panadeine overdose following relationship breakdo…

psychiatryemergency medicinecommunicationsystemparacetamol
VICaged care2012-04-30

Finding into death of Kenneth Agnew

37y · Male·combined ethanol and drug toxicity

Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…

general practicegeneral medicinediagnosticcommunicationmethadone
VIChospital2012-04-19

Finding into death of James Kellock Bloomfield

53y · Male·severe burns

Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-immolate due to distress about power cuts at h…

emergency medicinepsychiatrycommunicationsystem
NSWmental health2012-04-17

Coroner's Finding: DB

28y · Male·ligature strangulation

DB, a 28-year-old with first episode psychosis, was admitted to Nepean Hospital on 31 March 2009 after self-harming. He was appropriately diagnosed and treated with olanzapine under the Mental Health Act. Two independent…

psychiatrycommunicationsystemolanzapine
VIChospital2012-04-12

Finding into death of Gayle Maree Johnson

51y · Female·Complications of anorexia nervosa

A 51-year-old woman with severe anorexia nervosa, BMI 12.1, was admitted to hospital acutely unwell with hypothermia, bradycardia, heart block, and extreme malnutrition. She was discharged after only 2 days with minimal …

psychiatryemergency medicinediagnosticcommunication
VICaged care2012-04-04

Finding into death of Alexsandra Birute Volkas

85y · Female·Coronary artery disease and heat exposure

An 85-year-old woman with coronary artery disease was admitted to a low-care supported residential service following bowel surgery. She was frail, hard of hearing, wore spectacles, and showed signs of confusion and distr…

geriatric medicinepsychiatrysystemcommunication
WAhome2012-04

Inquest into the Death of BENFIELD

0y · Female·Unascertainable

Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …

paediatricspsychiatrysystemdelay
WAhospital2012-03-30

Inquest into the Death of Ellery

25y · Male·Ligature compression of the neck (hanging)

David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …

emergency medicinepsychiatrycommunicationsystemamphetamine
VICcommunity2012-03-23

Finding into death of Simon Rhys MacQueen

34y · Male·head and neck trauma (train impact)

Simon MacQueen, a 34-year-old man with chronic schizophrenia and recurrent suicidality, died by stepping in front of a train on 15 December 2008. He had been discharged from inpatient psychiatric care on 12 November 2008…

psychiatrygeneral practicecommunicationsystemrisperidone
VICmental health2012-03-13

Finding into death of Matthew Spalding

28y · Male·neck compression subsequent upon hanging

Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health …

psychiatryemergency medicinecommunicationsystemaripiprazole
NT2012-03-07

Inquest into the death of Robert Martin Johnson

34y · Male·asphyxiation by hanging

A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …

psychiatrygeneral practicediagnosticsystem
VICmental health2012-03-06

Finding into death of Nikos Karagiannis

26y · Male·Unascertained on an unequivocal medical or pathological basis; likely multifacto…

Nick Karagiannis, a 26-year-old man with schizophrenia, obesity, and significant hepatic steatosis, died unexpectedly at Thomas Embling Hospital's secure psychiatric unit. He was found unresponsive in bed after having no…

psychiatryforensic medicinedelaysystemclozapine
VICcommunity2012-03-01

Finding into death of K

33y · Male·complications from blunt force trauma to head consequent upon being struck by a …

A 33-year-old man with long-standing substance abuse and acute methadone withdrawal presented with suicidal ideation on the morning of 11 February 2007. The Crisis Assessment and Treatment (CAT) Team assessed him at 5pm …

psychiatrygeneral practicediagnosticcommunicationmethadone
VIChospital2012-02-29

Finding into death of Joanne Feeney

40y · Female·Multiple injuries sustained in a fall from a height followed by being struck by …

A 40-year-old woman with a history of substance abuse and a prior suicide attempt in August 2010 presented to Northern Hospital at 2am with chest pain. Diagnosed clinically with pleurisy from lower respiratory tract infe…

emergency medicinepsychiatrysystemmethamphetamine
QLDhospital2012-02-21

Vaggs, Lyji

28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…

Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…

psychiatryemergency medicinediagnosticmedicationolanzapine
SAhome2012-02-20

Coroner's Finding: WYATT David James and WYATT Jakob James

24y · Male·Blood loss due to multiple stab wounds to chest and multiple incised wounds of n…

A 24-year-old man with schizoaffective disorder and substance abuse killed his 2-year-old son and himself in March 2009. The deceased had been released on licence following a mental impairment finding and was subject to …

psychiatrycorrectional healthsystemcommunicationmethamphetamine
VIChome2012-02-15

Finding into death of James

24y · Male·Combined drug toxicity (morphine and diazepam)

James, aged 24, died from combined drug toxicity (morphine and diazepam) following intentional overdose. He had engaged in prescription shopping across 19 doctors and 32 pharmacies over three years, obtaining large quant…

general practicepsychiatrysystemcommunicationmorphine
VICmental health2012-01-31

Finding into death of John Bernard Tuffy

48y · Male·drowning

John Tuffy, 48, died by drowning after absconding from a mental health waiting room at Bayview House while awaiting transfer to hospital. He had returned from Ireland with acute psychosis triggered by his mother's sudden…

psychiatryemergency medicinecommunicationsystemtemazepam
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