1,641 results
Unknown·Incineration from a house fire. The children were subject to poor supervision fr…
Two young children (aged 3 and 2 years) perished in a house fire in 2008 while under the supervision of their grandmother, who had been previously determined by the Department of Child Safety to be inappropriate for this…
18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hangi…
An 18-year-old Aboriginal man died from hypoxic brain injury following cardiac arrest from hanging. He had a chronic petrol-sniffing habit and was acutely intoxicated on petrol when he hanged himself after a police incid…
34y · Male·cardiomegaly with contributing aspiration
A 34-year-old man with paranoid schizophrenia, morbid obesity, type 1 diabetes, and undiagnosed sleep apnoea died from cardiomegaly with contributing aspiration while detained under the Mental Health Act. On 6 March, he …
47y · Female·risperidone toxicity
Rosa Sinapi, a 47-year-old woman with delusional disorder, died from risperidone toxicity after ingesting an overdose of her antipsychotic medication. She had self-escalated her risperidone dose from 3mg to 6mg daily wit…
29y · Male·acute bronchopneumonia complicated by multi-drug toxicity
Nicholas Ang, aged 29, with schizoaffective disorder, died from acute bronchopneumonia complicated by multi-drug toxicity while in a psychiatric unit. Admitted 12 August 2005, he was on clozapine, valproic acid, and clon…
50y · Female·compression of the neck consistent with hanging
Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…
41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)
Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) while detained in Ward 5H of the Margaret Tobin Centre ps…
21y · Male·Suicide by hanging
A 21-year-old Aboriginal man with schizophrenia and depression died by suicide in prison custody. Key clinical failures included: (1) inadequate mental health assessment by Dr S.—45-minute screening reviewing only one of…
50y · Male·Chronic liver disease (alcohol, hepatitis C) with hepatocellular carcinoma and c…
Noel Robert Rogerson, a 50-year-old prisoner with chronic liver disease (alcohol-related cirrhosis and hepatitis C), died from decompensated liver disease with hepatocellular carcinoma on 28 March 2009 at St Vincent's Ho…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
Lisa Sharp, 34-year-old woman on a Community Treatment Order for schizophrenia, depression, and anxiety, died by hanging on 16-17 December 2007. She was in severe distress over losing custody of her children, with a cour…
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
41y · Female·Hanging
Patricia Webster, a 41-year-old with a history of major depressive disorder, was admitted to hospital on 8 October 2009 after stopping antidepressants. She was discharged on 21 October with community mental health follow…
25y · Male·hanging
A 25-year-old university student with a complex history of schizoaffective disorder and substance misuse died by hanging during family leave from a mental health ward. He had been stable on depot antipsychotic medication…
50y · Male·Pneumonia
Anthony Mandel, a 50-year-old man with intellectual disability and schizophrenia, was admitted to Box Hill Hospital on 4 May 2007 following an acute psychotic episode. He was transferred to a mental health unit, then bac…
84y · Male·Aspiration pneumonia associated with vascular and Alzheimer dementia
An 84-year-old man with vascular and Alzheimer dementia died from aspiration pneumonia at Latrobe Regional Hospital. He had been under an Inpatient Treatment Order, but this critical status was not communicated to the re…
42y · Male·Hanging (self-inflicted) while suffering from serious mental illness
Brian Dunningham, aged 42, died by hanging at Bathurst Correctional Complex (9–10 September 2009) while in custody. He had serious mental illness (psychosis, depression) requiring antipsychotic and antidepressant medicat…
1y · Male·Complication of burns and trauma to the mesenteric artery
A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
Unknown·Gunshot wound to the head (self-inflicted)
Two suicides occurred at a commercial firing range where individuals gained easy access to firearms. Julia Morris, 23, with documented borderline personality disorder and recent suicide attempt, was discharged from hospi…
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