390 results for “mental health deterioration”
27y · Male·hanging
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. H…
45y · Female·Complications of acute alcohol intoxication
…ts with treatment-resistant schizophrenia. Earlier intervention upon discovering her absence and rapid deterioration might have improved outcomes.
78y · Male·large left basal ganglia intracerebral haemorrhage with mass effect
John Joseph Tiernan, 78, died from a large left basal ganglia intracerebral haemorrhage with mass effect while admitted under an Inpatient Treatment Order (ITO) for acute hyperactive delirium. He had stage 4 lung cancer …
17y · Female·Combined Drug Toxicity (heroin, alprazolam and diazepam)
A 17-year-old female with complex mental health and substance use disorders died from combined drug toxicity (heroin, alprazolam, and diazepam) fol…
72y · Male·Hanging
A 72-year-old male inmate at Long Bay Correctional Centre died by hanging in April 2017. He had a documented history of depression managed with antidepressant medications, and his medication (mirtazapine) was adjusted tw…
63y · Male·Respiratory failure due to acute exacerbation of chronic obstructive airways dis…
…pidly despite treatment. The coroner found care and management were within normal parameters of reasonable health care practice. The clinical lesson is that multiple exacerbations in short timeframe may warrant escalatio…
39y · Male·Multi organ failure complicating acute paraquat and diquat toxicity
…oca-Cola bottle on 10 June 2006, arriving at hospital significantly intoxicated. He was detained under the Mental Health Act and transferred from Lyell McEwin to Royal Adelaide Hospital where he died. The coroner found h…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
…g his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental health services despite clear evidence of florid psychosis. The GP refused detention under the Mental Heal…
19y · Female·2,4-dinitrophenol toxicity
A 19-year-old woman died from 2,4-dinitrophenol (DNP) toxicity after intentionally ingesting approximately 50 x 250mg capsules purchased online. She presented to Flinders Medical Centre with an Inpatient Treatment Order …
36y · Male·Alcohol toxicity from consumption of Listerine mouthwash
… consumption of a 1-litre bottle of Listerine mouthwash. He was an involuntary patient at Bridgeview House mental health unit when found unresponsive at 7am on 15 December 2014. Nursing observations every 2 hours showed …
38y · Male·Exsanguination due to penetration of arm veins
…the months before death, he became non-compliant with psychiatric medication despite treatment from prison health services. Although reviewed by a mental health nurse specialist on 24 April 2008 who noted fleeting suicid…
29y · Male·Injuries sustained in a fall from a height
…des despite treatment with antipsychotic medications including olanzapine. In the months before death, his mental health deteriorated significantly; he lost employment and repeatedly refused medication reviews. His psych…
63y · Male·Incised injuries to the neck and upper limbs
…chiatric care in July 2022, ceased prescribed medications, and self-prescribed cannabis oil. His community mental health service discharged him in September 2022. A post-mortem neuropathology examination revealed stage 3…
16y · Female·mixed drug toxicity (oxycodone, citalopram, fluoxetine and quetiapine)
…sonality disorder, reactive attachment disorder, and suicidal ideation. Following escalating behaviour and mental health deterioration, she was placed in residential care (MacKillop) on 17 October 2013, with a Placement …
73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…
… severity of his condition to enable informed decision-making, may have altered the outcome. The rapid deterioration and early death underscore the seriousness of untreated pneumonia in this population.
58y · Male·effects of chronic alcoholism
… sepsis, and multiple intracranial haemorrhages. While he sustained a fall on 13 October 2016 whilst under mental health detention, the coroner found this did not significantly contribute to death. The underlying cause w…
57y · Female·Injuries sustained when struck by a train
…erly documented or executed. Critical systemic failures included: communication gaps between ED and ECATT (mental health crisis team), incomplete handover of care plans, inaccessible medical records, and unclear document…
19y · Male·Hanging
…eensland) on 17 March 2011. He had a history of self-harm evident from scars on his forearms, noted during mental health screening on 9 December 2010. The screening nurse appropriately assessed him as low risk despite th…
37y · Male·Sergeant Huitson: gunshot wound to chest and abdomen; Ansell: multiple gunshot w…
…uiry examined a shooting incident on 3 August 1999 where Rodney Ansell, a man suffering from deteriorating mental health and chronic amphetamine abuse, opened fire on the Stuart Highway killing Sergeant Glen Huitson and …
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
…m reporting CTH's hallucinations, paranoia and drug use, paramedics and police assessed him as not meeting Mental Health Act thresholds for involuntary admission. The coroner identified system failures in Child Protectio…
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