391 results for “psychiatric medication management”
47y · Male·Compression of the neck arising from hanging
…ior staff, without directly contacting his GP, and without family engagement. The coroner found clinical management deficiencies but not causally related to death. Key lessons: escalate complex cases to senior staff, ens…
63y · Female·unable to determine; possibly mirtazapine toxicity, cardiac disease, or injectio…
…but factitious disorder was not identified during treatment. Enhanced collaboration between medical and psychiatric teams, and awareness of this disorder's presentations, may have enabled earlier recognition and appropr…
17y · Female·multiple blunt force injuries after being struck by a train
17-year-old X died by suicide on 18 December 2012 after being struck by a train. She received multiple psychiatric admissions and CAMHS outpatient care from July-December 2012 for suicidal ideation, overdose attempts, …
58y · Male·Combined drug toxicity (eucalyptus oil, alcohol, venlafaxine, quetiapine, propra…
…conded from his supported residential service and was found deceased. The coroner found Austin Health's psychiatric assessment and management suboptimal, highlighting failures to: utilise relapse prevention plans, antic…
45y · Female·Multi-drug toxicity
…pressants despite documented drug and alcohol dependence, 15+ prior overdoses, cognitive impairment and psychiatric vulnerability. Critical failures included: lack of pain assessment justifying opioids; prescribing outd…
28y · Male·Multiple injuries sustained when struck by a freight train
…idal ideation, a concrete plan involving knowledge of train timetables, and low protective factors. The psychiatric registrar assessed him as low risk and discharged him alone just before midnight without informing his …
54y · Male·Died by hanging while suffering from the effects of Post-traumatic Stress Disord…
… January 2007, he received appropriate treatment from a GP and clinical psychologist, but struggled with medication compliance and experienced persistent suicidal ideation. The clinical challenge was managing comorbid PT…
71y · Male·Organ failure in an elderly man receiving palliative medical care for renal fail…
…ultiple comorbidities including COPD, early gastric carcinoma (treated with gastrectomy), diabetes, and psychiatric illness. His complex medical and mental health needs were managed through prison medical staff and exte…
41y · Male·head and chest injuries from fall from height
…tempts, previously managed with antipsychotic injections and antidepressants. Critical clinical lessons: medication non-adherence was the key factor—toxicology showed he hadn't taken prescribed paliperidone or venlafaxin…
47y · Male·Extensive burns sustained in a deliberately set fire
…l ideation. He presented to hospital twice in the preceding weeks with suicidal thoughts, was prescribed medication, and received follow-up care including a Mental Health Plan and psychologist referral. Despite professio…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
…ers Hill Nursing Home on 18 November 2011, set by drug-dependent nurse Roger Dean to destroy evidence of medication theft. Dean had worked while visibly intoxicated at a previous hospital (St John of God) but this was no…
22y · Male·acute blood loss from incised injuries to left forearm
… requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treatment decisions and did not meet criteria for involunta…
31y · Male·Self-inflicted hanging
…ified: previous high-risk assessments from 1998–1999 were not available to 2004 staff due to poor record management; mental health services were severely under-resourced with only one psychiatric session weekly for 400 p…
45y · Male·Self-inflicted burns (80-90% full and partial thickness burns across body)
Stephen Mawer, a 45-year-old man with longstanding depression, anxiety and suicidal ideation, died from severe burns sustained when he deliberately set himself alight during a police siege at his home. He had recently be…
58y · Male·blunt force head injury
…cluded poor communication of his Community Treatment Order (CTO) across healthcare settings, inadequate psychiatric supervision, insufficient clinical information provided to the assessing GP on the day of his death, an…
47y · Female·Multiple injuries from being struck by a train; death determined to be suicide
…y Treatment Order at the time. Critical clinical lessons include: (1) discharge planning from inpatient psychiatric care was inadequate, with serious miscommunications between Swan Valley Centre and Inner City Community…
34y · Male·Gunshot injuries to chest and left shoulder
…e was not placed on a Community Treatment Order (CTO) and did not receive prescribed depot antipsychotic medication following releases from prison in March and July 2021. After his mother reported severe paranoia in Octo…
34y · Female·Combined drug toxicity (propofol, sevoflurane and others)
…er GP and employer to recognise her substance misuse and mental health deterioration; (3) her declining psychiatric follow-up despite referral in 2010 and advice to see a psychiatrist in 2012. The hospital subsequently …
Unknown·Multiple injuries from motor vehicle accident; Anthony Paul Thomson died from ru…
… to the Department of Transport. However, the coroner found no clinical fault with his treating doctors' management of his complex medical conditions (brain injury, ADHD, anxiety, depression, chronic pain) or their asses…
44y · Male·Ligature compression of the neck (hanging)
Geoffrey Stephen Ward, a 44-year-old involuntary psychiatric patient at Graylands Hospital with chronic paranoid schizophrenia, died by hanging on 20 February 2000.…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.