273 results for “depressive disorder”
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
47y · Female·plastic bag asphyxia
A 47-year-old woman with depression following relationship breakdown was admitted involuntarily to St Vincent's Mental Health with high suicide risk. After 2 days in the secure Extra Care Unit, she was transferred to the…
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…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
50y · Female·compression of the neck consistent with hanging
Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…
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…
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…
34y · Male·Asphyxia consistent with plastic bag asphyxia
A 34-year-old male in pre-trial custody at Arthur Gorrie Correctional Centre died by asphyxiation using a plastic bag on 3 September 2008. He had a psychiatric history with prior suicide attempts and was on olanzapine. H…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
… continuous rather than close observations, and that key psychiatric warnings (paranoid comments, thought-disordered writings) were not adequately communicated to treating psychiatrist Dr S., who should have reassessed a…
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…
69y · Male·asphyxia by hanging
A 69-year-old man with depression, prostate cancer, and recent suicide attempt was admitted to MAPU (general medical ward) after intensive care treatment. He was deemed low suicide risk and the one-on-one attendant was d…
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…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
5y · Male·Presumed drowning
CS, aged 5 years 9 months, died by presumed drowning on 2 March 2017 in the Murray River, Moama NSW. His mother LS, who was mentally unwell and using ice, forcibly held him underwater. Multiple agencies—FACS, NSW and Vic…
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 …
Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…
Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…
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…
39y · Male·Ligature Compression of the Neck (Hanging)
Gerhardus Theron, 39, died by suicide in a remand centre on 25 June 2000 by ligature compression of the neck. He had murdered his wife on 28 April 2000 while their four children were present, and was remanded in custody.…
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…
53y · Female·mixed prescription drug toxicity
…n Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity involving venlafaxine, methadone…
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