27y · Male·Multiple injuries sustained after being struck by a train
… formal reassessment occurred post-meeting despite known risks with Cluster B personality disorders and impulsivity. The coroner identified missed opportunities to intervene. Risk assessments for patients with personali…
33y · Male·cerebral hypoxia due to compression of the neck (suspension)
Leim Matthew Benson, 33, died from cerebral hypoxia due to neck compression by suspension on 4 April 2007. He died 3 days after being found hanging from a residential balcony on 1 April 2007 following an argument with hi…
60y · Male·Drowning; elevated blood ethanol level
Nicholas Lobo, aged 60, died by drowning with elevated blood alcohol (0.21%). He was discharged from acute psychiatric inpatient care to a rehabilitation facility on a Community Treatment Order after recent diagnosis of …
70y · Female·pneumonia and post-surgical course following repair of neck of femur fracture, i…
… discussions. The coroner found falls prevention measures were suitable and her falls resulted from her impulsivity and failure to use mobility aids. No clinical errors or preventability issues were identified. The case…
53y · Male·ligature compression of the neck (hanging)
…ation for years, showed no recent depression, and gave no warning signs. The death resulted from sudden impulsivity rather than foreseeable risk. The coroner accepted that while removing the shower hose would have been …
59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…
…kinson's disease. Post-operatively, he experienced significant behavioural changes including agitation, impulsivity, and mood disturbances. Critical failures in post-operative care contributed to his death: the treating…
34y · Male·Neck compression by hanging
…ment of rapidly changing presentations, over-reliance on verbal denials of ideation without considering impulsivity and cultural factors, lack of continuity in psychological care, insufficient consideration of contextua…
92y · Male·Head and neck injuries sustained in a fall in a man with multiple co-morbidities
…on to assist him to his room safely. While this intervention may not have prevented his death given his impulsivity and comorbidities, the inadequate supervision was sufficiently connected to the circumstances of death …
54y · Male·unascertained cause
… and recent cessation of contact with his clinical psychologist and GP. His psychologist had documented impulsivity, poor distress tolerance, and noted his children were his only protective factor. The coroner found Gui…
92y · Male·Consequences of accidental fall at RACF: post-operative delirium, left femoral i…
…ars old, taking three medications including a benzodiazepine that increase fall risk, having documented impulsivity regarding mobility, and lacking a comprehensive care plan following transition to permanent residency. …
19y · Male·Multiple injuries sustained in motor vehicle collision (driver); impact of vehic…
Steven Johnstone, a 19-year-old P-plate driver with a blood alcohol level of 0.19% (nearly four times the probationary driver limit), drove at extreme speeds of 150-200 km/h through residential areas on 17 January 2010, …
35y · Male·neck compression from hanging
…continuity of care before discharge, particularly for vulnerable patients with organic brain damage and impulsivity. Better discharge processes, mandatory GP notification, and consideration of community mental health te…
Suicide by jump from height and rail suicide
This research summary, prepared by the Coroners Prevention Unit at direction of Coroner Audrey Jamieson, analyzes jump from height and rail suicides in Victoria (2000–2012). Of 313 jump from height suicides identified, 3…
76y · Female·Effects of fire in a woman with head and neck injuries
…asis on Rudolf's autonomy and treatment refusal overshadowed assessment of his cognitive impairment and impulsivity, and his ability to make decisions affecting his wife's safety and care.
36y · Male·Ligature compression of the neck (suicide by hanging)
…ment on mental health monitoring would not have prevented his death given the acute destabilization and impulsivity inherent to his condition, she emphasised that proper psychiatric assessment at reception, ligature min…
75y · Female·postoperative delirium/exacerbation of community acquired pneumonia following le…
A 75-year-old woman with chronic kidney disease, anemia, and significant mobility impairment fell in her aged care facility despite documented high falls risk and appropriate preventive measures. She sustained a neck of …
36y · Male·Hanging
Brian Matthew Roberts, aged 36, died by hanging while on home detention bail in Berri, South Australia on 22 March 2014. He had been charged with rape offences and was subject to bail conditions including electronic moni…
99y · Female·pneumonia due to a fractured right neck of femur (hip) sustained in a fall
A 99-year-old woman with advanced dementia resident in aged care fell and sustained a right femoral neck fracture. Despite being assessed as high falls risk with multiple prevention measures in place, she was not wearing…
59y · Male·incised injuries to the neck
Paul McLoughlin, a 59-year-old man with long-standing bipolar affective disorder, schizoaffective disorder, and heavy cannabis use, died by suicide via incised neck wounds while on day leave from Graylands Hospital. He w…
62y · Male·end stage renal failure complicating oxalate crystal nephropathy with contributi…
Stewart Anthony Leane, 62, died from end-stage renal failure due to oxalate crystal nephropathy with contributing head injury. He had complex medical needs including dialysis-dependent kidney failure, schizophrenia, and …
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