346 results for “mental health distress”
44y · Female·Hanging
… an old-style cell with prominent hanging points. Multiple clinical opportunities were missed: the initial mental health screening failed to identify her known PTSD, anxiety and depression despite these being documented …
40y · Male·Haemorrhage from gunshot wound to chest
…or presumed hypomania/bipolar disorder with lithium and later antidepressants by his GP. A psychiatrist at mental health services assessed him briefly (1 hour), disagreed with the bipolar diagnosis, and recommended cessa…
43y · Male·Hanging
GS, a 43-year-old man with complex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in G…
32y · Female·Neck compression in the setting of self-suspension
… reported ongoing physical, sexual and psychological abuse to police on 12 May 2020 and was assessed under mental health legislation, disclosing suicidal ideation. A Family Violence Intervention Order was made on 14 May …
38y · Female·Multiple injuries sustained when struck by a train
…with management failing to conduct a proper investigation. Her complaints were handled informally at departmental level rather than escalated to HR despite being a multi-person bullying complaint. This mishandling, combi…
27y · Female·multiple gunshot injuries with a stab injury to the heart
…w acceptable standards and that it negated any chance of rapid police intervention. Penny had a history of mental health issues and substance use. The case highlights critical failures in emergency call-taking protocols,…
89y · Female·Ischaemic heart disease in a woman with a history of recent assault
…om vulnerable residents despite clear risk; (6) incidents were under-documented, downplaying severity; (7) mental health bed shortage contributed but did not excuse inadequate local supervision. Clinical lessons: violent…
19y · Male·Hanging
SF, a 19-year-old remand inmate with no prior custodial or mental health history, died by hanging in Goulburn Correctional Centre 18 hours after requesting protective place…
19y · Male·complications of ligature compression of the neck
… stated intent to harm himself and disclosed active self-harm; (2) staff were unaware of his deteriorating mental state and relationship breakdown with his partner; (3) lack of culturally safe care and limited Aboriginal…
Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…
…e-escalation strategies, or respond to medical staff warnings. Inadequate training on positional asphyxia, mental illness management, and handover procedures between police and hospitals were identified as systemic failu…
36y · Male·Acute on Chronic Myocardial Infarction
…o alert staff. The admission process treated the P10a form as a 'box-ticking' exercise rather than genuine health assessment. Key recommendations included installing cell alarms and monitoring cameras, providing welfare …
16y · Male·Consequences of high voltage electrical injury due to mental disorder/psychosis
…tient care. After discharge on 31 March 2020 with plans for Headspace outpatient follow-up, he was lost to mental health services within 9 days. No coordinated care plan existed between YIP and Headspace; responsibility …
18y · Male·Ligature compression of the neck (hanging)
…ldren and partner. Although initially placed on the Disturbed and Vulnerable list with recommendations for mental health monitoring and psychological follow-up, these recommendations were not implemented. A prior alleged…
75y · Male·Burns
…l ignition from a dropped cigarette, fire investigation evidence—including burn pattern analysis and experimental testing—indicated the fire originated at his trouser legs, consistent with deliberate ignition. Key clinic…
60y · Male·Neck compression secondary to hanging
…explicitly informed of elevated suicide risk, risk assessments must be contemporaneously documented, and a health-led intervention program (complementing police welfare roles) is needed for this high-risk cohort, as appr…
33y · Male·hanging
Brian Dewson, a 33-year-old man with a 12-year history of drug and alcohol abuse, multiple psychiatric assessments (antisocial personality disorder, depression), and prior suicide risk designations died by hanging in Por…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
… at MRRC from August 2021, his medical history was not reviewed on intake. Although he was identified as a mentally ill person on 3 September 2021 and ordered transferred to Long Bay Forensic Hospital, no bed became avai…
35y · Male·multi-drug toxicity
…ple deployments to Afghanistan and Iraq, domestic violence incidents, disciplinary proceedings, and failed mental health management. Critical failures included: deployment approval despite known PTSD despite initial refu…
Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…
Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was…
20y · Male·Hanging (wilful murder by Andrew Thomas Kranz)
…owing a drug overdose. A solicitor had previously reported concerns about his isolation and psychological distress. The coroner found he was murdered by another prisoner (Andrew Kranz, later convicted) rather than suicid…
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