47y · Male·self-inflicted stab wound to the chest with penetration of the left ventricle of…
…mirtazapine while in custody. In early December, following a bee sting, he reported fatigue, insomnia, and visual hallucinations. He attended a Community Corrections appointment on 13 December appearing well with no ment…
77y · Female·Asphyxia from manual strangulation and smothering
…ional beliefs since 2003 that significantly worsened in the days preceding the death, causing auditory and visual hallucinations. Following his arrest, he was found not guilty of murder on the grounds of insanity, with p…
28y · Female·Cerebral x-linked adrenoleukodystrophy
…rienced progressive deterioration from late 2022, with increasing neuropathic pain, cognitive decline, hallucinations, and visual loss. Her care involved palliative services, medication trials including fentanyl patches …
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
…s an involuntary patient in the High Dependency Unit experiencing acute psychotic relapse with command hallucinations. Clinical staff were present and responding appropriately to his acute agitation and behaviours. The f…
29y · Male·ligature compression of the neck (hanging)
…Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation following return from Bali. He was triaged as ATS…
61y · Female·Complications of pulmonary thromboembolism secondary to deep vein thrombosis
…the mental health unit, her physical health appeared stable though she exhibited suicidal ideation and hallucinations. She collapsed while washing her hands and suffered cardiac arrest from massive bilateral pulmonary em…
22y · Male·Head and neck injuries sustained in a train incident
Nicolas Russell Miles, aged 22, died from head and neck injuries after deliberately lying on railway tracks in front of a moving train on 12 January 2015. He had a history of anxiety, psychosis, and attention deficit dis…
18y · Female·Multiple injuries due to impact by train
…h services on 5 November 2012 despite ongoing high suicide risk, multiple recent overdoses, and active hallucinations of her attacker; (2) she was not registered with the Victims Register despite being entitled, meaning …
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
…e on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinations, stabbed MJU multiple times and KJH once. Despite MJU calling emergency services at 12:40pm…
24y · Male·Multiple injuries from a fall from height (seventh-floor balcony), with multiple…
Seth Luhrs, 24, died from multiple injuries sustained in a fall from a seventh-floor hotel balcony on 1 April 2018, whilst under the influence of LSD (lysergic acid diethylamide) and MDMA. Seth had ingested more than a l…
84y · Male·ischaemic heart disease on a background of advanced Lewy body dementia
An 84-year-old man with Lewy body dementia died from ischaemic heart disease while detained under a Mental Health Act order. He was admitted to hospital for management of aggressive behaviour related to his dementia. Dur…
46y · Female·hypoxic brain injury due to hanging
A 46-year-old woman with borderline and antisocial personality disorder, depression, and cannabis dependence died by suicide while an involuntary psychiatric inpatient. She had previously expressed suicidal ideation incl…
47y · Male·ligature compression of the neck (hanging)
…n SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which were reviewed by prison psychiatry and recommended for brain imaging and cultural counselling—n…
30y · Male·ligature compression of the neck (hanging)
…ed: inadequate communication of risk information to the psychiatrist (Dr B. received no details of his hallucinations, previous suicide attempts, or specific hanging plans), allowing him to close his cell door while alon…
31y · Male·Hanging
…d. Critical failures included: observations staff misinterpreting instructions regarding both physical and visual monitoring; failure to remove a covered CCTV camera for over 24 hours; falsified observation logs after hi…
62y · Male·Mr Evans: self-inflicted gunshot wound to head and asphyxiation by hanging. Mrs …
In September 2013, Mr John Evans (62) killed his wife Jillian after he experienced psychosis manifesting as delusions about chemical infestation of their home. The coroner found Mr Evans was psychotic at the time of deat…
39y · Male·Effects of fire (self-immolation)
…o the Latrobe Regional Hospital ED on 6 March 2022 with suicidal ideation, delusions of poisoning, and hallucinations. His GP's referral letter documented significant safety concerns. However, he was triaged as Category …
25y · Male·consistent with drowning in a man with multiple injuries
Warren Guneratne, a 25-year-old man with paranoid schizophrenia, was admitted involuntarily to the psychiatric unit of Royal Melbourne Hospital on 28 January 2008 after assessment by the Crisis Assessment and Treatment T…
20y · Male·head and neck injuries sustained when struck by train
Jordan James Williams, 20, died after being struck by a train following two absconsions from Kalgoorlie Health Campus mental health unit on 24 August 2018. He was involuntarily admitted with first-episode psychosis. Crit…
16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis
…to all stakeholders. The family made repeated distress calls describing deteriorating mental state and hallucinations but were repeatedly redirected without effective intervention. Six months later, with no medication, m…
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