216 results for “major depressive disorder”
77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression
77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
73y · Male·Neck compression in the circumstances of hanging
A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…
Male·neck compression due to hanging
…comprehensively assessed by a mental health nurse but received a wrong diagnosis of dysthymia (rather than major depression) from a non-psychiatrist, devastating his confidence in getting help. Neither man saw a psychia…
31y · Female·organ failure due to anorexia nervosa
…e; lack of coordinated transition from paediatric to adult services; absence of a robust statewide eating disorder service requiring her care to be fragmented across public, private, and primary care settings; and failur…
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…
Male·Gunshot wounds to the head
…ute services due to rural resource limits. On 1 June 2023, Wayne shot Noah then himself. The coroner found major failings in: inadequate record-keeping and inaccurate certification; incomplete assessment by Dr H.; inade…
Male·Multiple injuries due to train over-run (suicide by train)
Two separate suicides by train in July 2006 of young men admitted to Logan Hospital mental health services. Liam Wright (19) was transferred from the secure Acute Observation Area (AOA) to an open ward on 14 July 2006 de…
59y · Male·Gunshot wound of head
A 59-year-old police officer with 40 years service died by self-inflicted gunshot wound at his police station following severe financial stress related to property investment losses. He had received counselling and GP ma…
63y · Male·Multiple injuries due to fall from height
A 63-year-old man with Parkinson's disease died by suicide three days after discharge from hospital following reimplantation of a Deep Brain Stimulation (DBS) device. His initial DBS surgery in 2013 was successful, but d…
16y · Male·complications of ligature compression of the neck (hanging)
A 16-year-old Aboriginal youth, Cleveland Keith Dodd, died by suicide via hanging in Unit 18, a youth detention centre housed within an adult maximum-security prison in Western Australia. The coroner found Cleveland's de…
30y · Male·asphyxia due to hanging (suicide)
30-year-old Adam Trent Ryan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospita…
19y · Male·Ruptured aorta post motor vehicle incident
Simon Kirwan, 19, died by motor vehicle collision in circumstances indicating suicide after discharge from involuntary mental health care. He had made three serious suicide attempts within 7 days (overdoses, wrist lacera…
70y · Female·Gunshot wounds to the head and chest
Marilyn June Burdon, aged 70, was fatally shot by her intimate partner Charles Bisucci on 21 August 2017 in Kew, Victoria. Bisucci subsequently took his own life. Critical systemic failures enabled this preventable intim…
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…
80y · Male·Drowning
An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…
53y · Female·Hypoxic brain injury due to hanging
A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her deat…
34y · Male·Foreign body aspiration
A 34-year-old man died by foreign body aspiration while in custody at a correctional centre, three days after arrest for a serious violent crime. He fashioned an airway obstruction from toilet paper and meal pack plastic…
57y · Male·Head injury from fall; with coronary atherosclerosis and complete heart block wi…
A 57-year-old man with bipolar disorder died from head injury following a fall at Toowong Private Hospital. Critical failures in falls risk manag…
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.