264 results for “conduct disorder”
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulanc…
56y · Male·acute pentobarbitone toxicity
… team made critical deficiencies in the discharge decision on 1 September 2016. Dr K. and Dr S. failed to conduct a proper review of Mr Martin's extensive medical history, particularly the detailed Form 1 documenting de…
25y · Female·Chest injuries due to fall from height
…ient who threatened to jump the day of her death but was not assessed or reviewed; no risk assessment was conducted despite clinical deterioration postpartum. AW spent 462 days in an unsuitable acute ward, developed sev…
53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury
… 2008. He had been detained at Glenside Hospital on 10 April 2008 under the Mental Health Act for bipolar disorder with manic features, assessed as at moderate to extreme risk of absconding given his repeated history of …
22y · Male·Multiple injuries from fall from height
Mitchell Follent, 22, died by fall from a third-floor balcony five days after discharge from his first psychiatric admission for post-ictal/drug-induced psychosis. He had intellectual disability, epilepsy, and acquired b…
73y · Female·pneumonia and renal failure with hyperthermia
Beryl Jean Morgan, 73-year-old aged care resident, died from pneumonia and renal failure with hyperthermia after a brief hospital admission. She had been prescribed haloperidol for behavioural problems; while neuroleptic…
41y · Female·Multiple injuries
Alicia Maree Little, aged 41, was struck and killed by a motor vehicle driven by her former intimate partner while she was leaving the relationship. The case highlights significant systemic failures in family violence re…
27y · Male·gunshot injury to the head
A 27-year-old Western Australian police officer with a longstanding history of depression and anxiety took his own life using his police-issued firearm stored at home. He had struggled with mental health since 2017, atte…
Male·neck compression due to hanging
Two men died by suicide within five months of emergency department assessments at Lyell McEwin Hospital. Both had been brought in by police under Mental Health Act section 57 but were not detained and discharged after mi…
28y · Female·Multiple injuries sustained when struck by a truck on the M1 Pacific Motorway
Rachel Martin, a 28-year-old SNAP support worker and pregnant woman, died attempting to prevent harm to a high-needs child (Riley) during respite care transport. While driving Riley home on the M1 Motorway, Riley exited …
Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…
Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…
50y · Male·gunshot wounds to chest and abdomen
Alexander Kuskoff, aged 50, was fatally shot by STAR Group officer DA on 16 September 2015 following a mental health crisis. Kuskoff displayed florid psychotic symptoms including paranoid delusions, was heavily armed, an…
27y · Male·Sudden cardiac arrest in the context of physical and psychological exertion duri…
… LVNR application had temporal proximity to collapse, it was not the sole cause. The coroner found police conduct complied with policies; no criminal charges or disciplinary referrals were warranted. Key clinical lesson…
19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…
28y · Male·Hanging
…f self-harm attempts or escalating risk. The coroner found admission was the prudent course. Key lessons: conduct detailed substance use assessment, obtain collateral from all relevant parties, document and communicate …
52y · Male·Multiple blunt force injuries from a fall from height
A 52-year-old man with paranoid schizophrenia subject to a Community Treatment Order died from injuries sustained after jumping from a third-floor balcony during enforcement of the order. Mental health workers and police…
22y · Male·ligature compression of the neck (hanging)
Ricky-Lee Cound, 22, an Aboriginal man with FASD, died by hanging in his Hakea Prison cell on 25 March 2022. At 4.11pm, Mr Cound called requesting a monitored safe cell to prevent self-harm, demonstrating clear risk perc…
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·Right cerebral infarction caused by infusion of medication via central venous li…
A 63-year-old man with COPD, liver cirrhosis and alcohol dependence underwent emergency hemicolectomy for caecal volvulus. Post-operatively he developed respiratory depression, hypernatremia and alcohol withdrawal requir…
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