264 results for “conduct disorder”
Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …
29y · Male·hanging
Paul Skinner, a 29-year-old with depression and recent suicide attempt, was admitted to a psychiatric inpatient unit on involuntary status. Despite being prescribed 15-minute observations by his treating psychiatrist, nu…
40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…
Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy ca…
51y · Female·Complications of anorexia nervosa
…indicated she should have been involuntarily detained for stabilization and transfer to specialist eating disorders unit, or if discharged, required daily medical and nursing support. The hospital failed to recognize tha…
Infant W: asphyxia due to accidental overlay by parent in unsafe sleeping enviro…
Two premature infants died from unsafe sleeping environments while in the care of their parents, despite being subject to child protection notifications. Infant W (4 months) died from asphyxia due to accidental overlay i…
48y · Female·head injuries from multiple blunt force trauma including punching, elbowing and …
…leave was made by a covering consultant who did not review all available clinical information and did not conduct documented family discussion about risk management. Procedural failures included inadequate response to t…
72y · Female·Pneumonia following cervical spine injuries sustained in an unwitnessed mechanic…
…upervision directly led to the fatal fall. The underlying cause was St Michael's Association's failure to conduct substantive care reviews after she turned 65, particularly given documented concerns about dementia and f…
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…
24y · Male·Cardiac arrest in a man with Sotos syndrome and multiple comorbidities, includin…
… being restrained in prone position by PTA transit officers at Perth Underground Train Station. Following disorderly conduct and alcohol intoxication, officers used a harness takedown and handcuffs to detain him. While r…
Female·self-inflicted hanging (Fionica and Layla); hanging but circumstances open (Ketu…
Three Aboriginal teenage girls aged 15-17 years died by hanging in remote NT communities, all with documented histories of sexual abuse, domestic violence, STIs, injuries, and severe trauma. All were known to government …
21y · Male·Cardiorespiratory arrest associated with butane abuse by inhalation
A 21-year-old detained psychiatric patient died from cardiorespiratory arrest following deliberate butane inhalation in a hospital wardrobe. He was admitted to an open mental health ward following acute psychosis, with d…
27y · Female·neck compression
27-year-old Lynette Phillips died from neck compression (strangulation) at the hands of her intimate partner Benjamin Pappas in February 2007. Lynette had a documented history of family violence, drug dependency, and was…
82y · Female·traumatic closed head injury (subdural haematoma) resulting from a fall from sta…
…pitals when patients are readmitted shortly after discharge; verify discharge medication lists carefully; conduct complete pharmacy reviews despite staffing constraints; and file specialist correspondence in accessible …
18y · Male·methadone toxicity
…otocols; delayed and inadequate police investigation. The coroner found that had nightly room checks been conducted, Keough might have been discovered during the prolonged respiratory depression phase before death becam…
17y · Female·ligature compression of the neck (hanging)
A 17-year-old girl in state care died by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver…
24y · Male·Aspiration of vomit associated with combined drug effect
Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…
18y · Male·compression of the neck in keeping with hanging
… harm others. The referral was not actioned on the same day. A police welfare check was requested but not conducted. A locum GP visit provided only sedation for insomnia without comprehensive psychiatric assessment. Key…
41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)
Narisha Faye Cash, 41-year-old Aboriginal woman, died on 26 March 2020 from combined drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called…
32y · Male·asphyxia arising from neck compression from self-inflicted ligature strangulatio…
Glen Russell, 32, died by suicide in Cessnock Correctional Centre while on remand. He had a complex history including childhood sexual assault, schizophrenia diagnosis, heroin use, and recent self-harm episodes. Although…
48y · Female·Ischaemic bowel, with contributing conditions of coronary artery disease, diabet…
Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17…
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