304 results for “chronic suicide risk”
33y · Male·multi-drug toxicity as a result of misadventure
…m provided caring, coordinated, and comprehensive care. The coroner found no clear evidence Adam intended suicide at the time of the fatal overdose, given his history of non-intentional overdoses and absence of expresse…
29y · Female·Mixed drug toxicity (gamma hydroxybutyrate, methylamphetamine, amphetamine, diaz…
…pite a family violence intervention order. Clinical lessons include the need for integrated family violence risk assessment in mental health settings, recognition of the intersection between family violence, mental illne…
56y · Male·acute pentobarbitone toxicity
…f zopiclone, less than two weeks after premature discharge from involuntary mental health care. After two suicide attempts in July and August 2016, the psychiatric team made critical deficiencies in the discharge decisi…
23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…
A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide a…
47y · Male·ligature compression of the neck (hanging)
A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation,…
54y · Female·Acute alcohol toxicity with immersion
…ly satisfied that timely follow-up would have prevented her death, and could not determine whether it was suicide or accident. Southern Health implemented new protocols to prevent similar communication failures.
45y · Male·Shotgun wound to the head
…alth and addiction treatment needs (no rehabilitation facilities in far west NSW); understanding the lethal risk posed by untreated substance abuse combined with depression and firearm access; and the importance of famil…
34y · Male·Multiple Blunt Force Injuries
…untreated mental health issues combined with alcohol dependence and recent stressors significantly increase risk of impulsive, dangerous behaviour. Early intervention for alcohol use disorder and mental health management…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortn…
25y · Female·Ligature Compression of the Neck (Hanging)
…tasha Quartermaine, a 25-year-old female prisoner at Bandyup Women's Prison in Western Australia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, persona…
38y · Female·neck compression due to hanging
…manded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite comprehensive documentation from police identifying her as suicidal, at-risk, and recen…
18y · Female·Hypoxic brain injury secondary to hanging
…al management was reasonable, but identified systemic failures: hooks/housing posed an unacceptable hanging risk, safety audit processes failed to identify this, and a risk management report should have been completed wh…
46y · Male·Complications of ligature compression of the neck (hanging)
Sean Theo Winmar, a 46-year-old Aboriginal man, died by suicide on 11 August 2022 while on an interim supervision order after his release from prison. He had depression,…
33y · Male·hanging
…iatric hospitals when prison mental health services cannot provide appropriate care; better assessment of suicide risk in psychotic patients, particularly those with thought disorder and unreliable history; and importan…
24y · Female·Pentobarbitone toxicity
24-year-old Daniella Sessarego died from pentobarbitone toxicity following intentional ingestion. She had borderline personality disorder and depression with a history of self-harm and suicidality. On 12 August 2014, she…
54y · Male·hanging by ligature
Peter Ross Blunden, a 54-year-old man with chronic schizophrenia detained under the Mental Health Act, died by hanging in the shower room of Cramond Clinic …
43y · Male·suffocation by plastic bag (Neil Brooks); neck compression due to strangulation …
…ng to the remand centre. Brooks was subsequently placed in single-cell accommodation, which signalled low suicide risk to custodial staff. No self-harm notification forms were placed on file. Key issues: communication f…
13y · Male·Self-inflicted (manner recorded as intentionally self-inflicted; specific method…
…h assessment, initiated antidepressant therapy without proper screening or follow-up, failed to recognise suicide risk, and showed insufficient empathy or care. The child's school appropriately escalated concerns about …
50y · Male·Gunshot wound to the head
A 50-year-old RAAF Flight Sergeant with Major Depressive Disorder and anxiety died from a self-inflicted gunshot wound to the head after police responded to a domestic disturbance. He had received appropriate, evidence-b…
62y · Male·Cerebral ischaemic injury due to hanging
…is opposition, minimal improvement over 200+ treatments, and lack of alternative exhaustion; (2) inadequate risk assessment on 7 November when his suicide risk was downgraded to 'low' by a nurse unable to engage with him…
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