308 results for “family crisis”
31y · Male·hanging
Christopher Hunter, a 31-year-old with emerging paranoid psychotic disorder, was admitted to Delmont Private Hospital for 3 days before requesting discharge against medical advice on 9 June 2015. A senior registrar (Dr T…
34y · Male·Hypoxic-ischaemic brain injury caused by hanging
Craig Stevens, aged 34, died from hypoxic-ischaemic brain injury following a suicide by hanging on 17 June 2008. Despite police intervention, critical delays in cutting the ligature around his neck prevented timely resus…
Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…
…l below acceptable standards, particularly discharge decisions made hastily without adequate assessment or family consultation.
18y · Male·Ligature compression of the neck (hanging)
…roner expressed concerns about the inability to transition chronic suicidal ideation monitoring into acute crisis response, lack of psychiatric assessment despite his psychotic history, and poor continuity of care after …
Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…
This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…
49y · Female·Multi-drug toxicity from intentional self-administration of intravenous fentanyl…
A 49-year-old paramedic with Ambulance Victoria died from multi-drug toxicity after deliberately self-administering intravenous fentanyl and midazolam accessed from her employer's medication safe. The coroner examined wh…
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
…prehensive information-sharing between practitioners; warn patients about medication side effects; involve family in monitoring.
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
…ric infrastructure, seclusion facilities, and ECT capability for managing acutely aggressive patients; (2) Family communication was minimal despite their knowledge of de-escalation strategies; (3) Extubation was delayed …
Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…
…plified clinical judgment failures. Lack of integrated systems meant information from CERT assessments and family concerns was not properly incorporated into ongoing care. While resources and workload pressures contribut…
45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…
Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…
4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…
…ularly section 20(2) regarding mandatory drug assessments), failure to utilise available protective tools (family care meetings, investigation and assessment orders), inadequate investigation of 22 notifications, misinte…
20y · Male·Self-inflicted hanging
…ary means. While preventability cannot be proven, identifying and supporting vulnerable individuals during crisis and eliminating obvious suicide methods would reduce risk.
43y · Male·Hanging
Brett Andrew Pollini, a 43-year-old fire station officer with bipolar affective disorder, died by suicide following a distressing telephone call with the Child Support Agency (CSA) regarding a substantial increase in chi…
81y · Male·Hanging
…nces experience significant psychological stressors including shame, loss of reputation, social isolation, family dissolution, and unfamiliarity with the criminal justice system—creating elevated suicide risk. The findin…
suicide by hanging or other means
…melessness as an unaddressed risk factor, poor inter-agency communication, and lack of follow-up care post-crisis presentations. Key lessons: early intervention in infancy/toddlerhood is cost-effective and crucial; menta…
40y · Male·Haemorrhage from gunshot wound to chest
Lee Andrew Kennedy, a 40-year-old man with a history of mood instability, migraines, and medical treatment through a GP and psychiatrist, died from a gunshot wound to the chest inflicted by Constable Erin Levay during a …
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
…ications despite recognised eligibility. The coroner found systemic failures in inter-agency coordination, family engagement, and resource allocation, but did not find the death preventable given the confusing circumstan…
20y · Male·Multiple injuries from fall from height
…e from senior correctional officers; there was inadequate documentation of his distress on cell intercoms; family contact attempts were blocked; and the escort officers failed to maintain proper restraint during hospital…
26y · Female·hypoxic ischaemic encephalopathy and bronchopneumonia in a woman with methylamph…
…) Proper de-escalation and tactical communication are essential when apprehending persons in mental health crisis; (5) One-to-one observation of acutely psychotic patients should only be discontinued by medical staff; (6…
73y · Female·Unknown due to decomposition
…iving conditions. A psychiatrist's rushed capacity assessment did not adequately evaluate her cognition or family circumstances. The Hospital failed to make a guardianship application despite clear indicators of neglect …
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