390 results for “mental health deterioration”
85y · Male·end stage dementia
Lawrence George Harvey, aged 85, died from end-stage dementia while lawfully detained under the Mental Health Act at Noarlunga Hospital. He had experienced progressive dementia since 2013 with increasing aggre…
84y · Female·Myocardial infarction
…his indicating possible myocardial infarction. Significant anaemia (Hb 72, down from 127) and signs of deterioration (oliguria, tachycardia, drowsiness) were not adequately escalated or investigated. No MERT call was ma…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
…t disease complicated by undetected hyperkalaemia. Panella's death was not preventable given her rapid deterioration and atypical presentation, but occurred in undignified circumstances. Skeffington's death was preventa…
33y · Male·Contact range shotgun injury to the head
A 33-year-old man died from a contact range shotgun injury to the head while subject to a Mental Health Act apprehension order. Police conducted a six-hour operation involving 120 members across multiple…
25y · Female·Chest injuries due to fall from height
…r-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite being involuntary patients on observation regimes with leave …
44y · Female·Hanging
… an old-style cell with prominent hanging points. Multiple clinical opportunities were missed: the initial mental health screening failed to identify her known PTSD, anxiety and depression despite these being documented …
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 dement…
29y · Male·Incised injury to the neck
… life. Clinical lessons include: recognising untreated depression in military veterans; ensuring follow-up mental health support following compensation awards; monitoring patients with substance use and mood disorders; a…
43y · Male·hypoxic brain injury secondary to asphyxiation by ligature
A 43-year-old man died from hypoxic brain injury due to asphyxiation by ligature while an inpatient at a rehabilitation centre. He had undergone spinal surgery for back pain and cauda equina syndrome but was failing to i…
50y · Male·Single, contact-range shotgun discharge to the head
…on, unemployment, weapon access, and suicide risk in perpetrators of family violence. No medical errors or healthcare system failures were identified. The coroner notes the heightened suicide risk in family violence perp…
61y · Male·Undetermined
…l 2015 and subsequently died on 5 April 2015 from an undetermined cause. Clinical lessons include: Eastern Health sedation guidelines were not followed; vital sign monitoring ceased at 7:45am on 4 April despite guideline…
30y · Male·Hanging
…der the High Risk Assessment Team (HRAT) regime during an earlier 2017 remand. Despite clear indicators of mental health deterioration (anxiety, paranoia, disclosed childhood sexual abuse), a Notice of Concern was never …
56y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
…n late 2018 despite advice, initially declining further appointments. In August 2019, after observable deterioration (increased alcohol use, mood lability, marital stress), he re-engaged with treatment and restarted ant…
53y · Female·unascertained natural causes
…ined. The case highlights the challenges of managing catatonia in psychiatric settings. Post-incident, the health service implemented improvements including formal training on catatonia recognition and escalation procedu…
36y · Male·Cannot be determined
CD, aged 36, disappeared on 17 June 2019 after exhibiting significant mental health deterioration, recent suicidal ideation, paranoia, alcohol abuse, and relationship breakdown. The c…
Male·consistent with the history of hanging
…custody on his first remand in prison. He had been charged with serious offences and refused bail. Justice Health conducted initial screening, diagnosed situational crisis with low self-harm risk, and maintained monitori…
33y · Male·Argon gas and plastic bag asphyxia
…m, which now has mandatory safety standards, argon regulation has been rejected twice by the Department of Health. No preventive opportunities were identified in the clinical care pathway.
18y · Male·neck compression due to hanging
…accommodation in April 2006. He had Aspergers Syndrome diagnosed at age 4, with escalating behavioural and mental health crises from adolescence. Despite multiple emergency department presentations and psychiatric admiss…
60y · Male·Mixed drug toxicity
…antipsychotic medication (trifluoperazine) due to manufacturer discontinuation. He waited over 7 hours for mental health assessment but none was provided due to unplanned staff leave. Mental health services had no backup…
72y · Male·Bronchopneumonia in the setting of chronic aspiration in a man with mixed Alzhei…
…sychogeriatric facility. He had severe ischaemic heart disease and prostate cancer. Despite placement on a Mental Health Act treatment order due to aggressive behaviour, he received appropriate palliative care once clini…
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