391 results for “psychiatric medication management”
33y · Female·Hanging
…der died by hanging while voluntarily admitted to a mental health inpatient unit. She was stabilizing on medication and scheduled for transfer to a private facility. The coroner found reasonable and appropriate care was …
30y · Male·asphyxia due to hanging (suicide)
…ours after discharge, nursing staff failed to appropriately escalate concerns, provided him unrestricted medication on discharge, and failed to locate him when he went missing from hospital. Staff later improperly rewrot…
38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia
…in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to prison on 20 July 2007 with stabilised clozapine therapy monitored through regular blood te…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
… Power of Attorney) progressively restricted her diet to steamed vegetables and fruit, discontinued all psychiatric and cardiac medications based on internet research and religious beliefs, and limited her medical consu…
14y · Female·electrocution
…tic rather than secure care model is needed; (6) System requires substantial investment in foster care, psychiatric resources, and early intervention.
71y · Male·general inanition on a background of end-stage mixed pattern dementia and acute …
…nfection. During hospitalization, he experienced multiple falls related to dementia progression, refused medications and oral intake, and ultimately required palliative care. The coroner found the ITOs were lawfully impo…
46y · Male·Acute hypoxic brain damage resulting from intentional self-inflicted hanging
…ody. He had a history of physical health issues including HIV and mental health concerns including anger management difficulties. Despite appropriate mental health assessments, psychological counseling, and medical care …
59y · Female·Mixed drug toxicity, with metoprolol at toxic level; coronary atherosclerosis as…
…case manager (RN Gulliver) provided appropriate clinical care, including urgent home visits and earlier psychiatric appointments. However, communication with non-government organisation staff was perceived as dismissive…
51y · Male·undetermined natural causes
Chris Prasad, a 51-year-old involuntary psychiatric inpatient with schizoaffective disorder, diabetes type 2, hypertension, and obesity (BMI 30.8), was gra…
35y · Male·Complications of morbid obesity in a man with cardiomegaly and schizophrenia
…udden cardiac death. The coroner identified systemic care gaps: no documented communication between his psychiatric service (Casey Continuing Care Team) and general practice (Pound Medical Centre) after March 2015, desp…
62y · Female·Hypoxic brain injury complicating mixed drug toxicity
…Mildura Base Hospital Emergency Department. She had presented after a suspected overdose of prescription medications on 5 September in the context of severe marital breakdown and a prior serious suicide attempt in July. …
36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…
… creating unsustainable span-of-control ratios (one duty manager responsible for 180+ staff), inadequate medication management and security enabling Crump to steal drugs repeatedly undetected, failure to investigate susp…
41y · Male·complications in association with effects of fire, with terminal palliative care
…Order. Wilson was discharged from Graylands Hospital on 29 October 2021 following a 12-day admission for management of psychosis and recent suicidal behaviour (drain cleaner ingestion). Key deficiencies included: failure…
69y · Male·Partial contact range gunshot wound of the head
…hronic suicidal ideation, died by gunshot wound to the head on 25 September 2017. He had been receiving psychiatric care from Dr McDougall and case management from community mental health services. Following a July 2017…
27y · Male·Hanging
…g in excessive workloads, long consecutive shifts (up to 14 hours), and minimal time off. Despite being psychiatrically stable and compliant with medication, Marcus developed significant workplace stress from December 2…
53y · Female·Hypoxic brain injury due to hanging
A 53-year-old woman with severe depression, anxiety, and recent suicide attempt died by hanging in a psychiatric hospital's low-dependency unit. She had received ECT and was on hourly observations. On the day of her …
27y · Male·compression of the neck due to hanging
… longitudinal history showed likely relapsed psychosis with probable bipolar disorder. After discharge, psychiatric care was fragmented with poor communication between services. Theo presented to emergency twice in Janu…
42y · Male·hanging
… Key clinical lessons: (1) risk assessments are ephemeral and vulnerable to manipulation; (2) cancelled psychiatric appointments were not reliably rescheduled; (3) rapid de-escalation of observation status in high-risk …
18y · Female·Hypoxic brain injury secondary to hanging
An 18-year-old woman with major depressive disorder and PTSD was admitted to a psychiatric inpatient unit after expressing suicidal ideation and self-harm. She was changed from involuntary to vo…
56y · Female·Bronchopneumonia in the setting of supratherapeutic lithium levels
… bronchopneumonia in the setting of supratherapeutic lithium levels. She was on lithium 1250 mg/day for psychiatric management and fluid restriction (1.5 litres/day) for fluid retention. Despite GP reviews showing clini…
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