318 results for “substance use (cannabis)”
25y · Male·Aspiration pneumonia secondary to methadone toxicity
…e Alexander Maconochie Centre in the ACT. He was assessed as opioid naive despite representations of heroin use and prescribed 30 mg methadone daily after two doses. The coroner found the medical assessment and prescrip…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
42y · Female·Ligature compression of the neck (hanging)
Sheridan Troy Hilton, a 42-year-old woman with a history of depression and substance abuse, died by suicide on 31 August 2003 while in an unwell mental state. She experienced significant ps…
32y · Male·Gunshot wound to head (self-inflicted)
…binson, a 32-year-old registered child sex offender and parolee with a long violent criminal history and substance abuse problems, died by self-inflicted gunshot wound while evading police during a siege at a rural prop…
53y · Male·severe burns
Mr Bloomfield, a 53-year-old man with complex psychiatric and substance abuse history, was apprehended by police under section 10 Mental Health Act after threatening to self-im…
37y · Male·hypoxic encephalopathy due to asphyxia from hanging
Joseph Aaron Lattimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring ass…
33y · Male·hanging
…ention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attempt in 2016. Clinical lessons include: the PSP/SME monitoring syste…
31y · Male·hanging
Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…
17y · Female·Neck compression by hanging (suicide)
…l guardian. Critical failures included: inadequate cultural connection and support, poor case management focused on crisis response rather than relational practice, failure to facilitate family contact despite court ord…
72y · Male·Multiple stab and incised wounds to the chest and neck
Barry Gray, aged 72, was killed by his 22-year-old neighbor John Woodruff on 16-17 May 2013. Woodruff had been diagnosed with first episode psychosis in prison and released on a Community Corrections Order (CCO) on 30 Ap…
31y · Male·mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen)
A 31-year-old man subject to a post-sentence supervision order died from mixed drug toxicity (methadone, diazepam, pregabalin, promethazine, pizotifen) at a residential facility. He was a vulnerable person with acquired …
24y · Male·Strangulation by hanging
Dean Laycock, a 24-year-old man with intellectual disability and psychosis, died by hanging on Christmas Eve 2009, four hours after being informed that his anticipated 4-day Christmas leave from PARC (a psychiatric step-…
23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…
A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric dischar…
41y · Male·Stab wound to the chest
…y during a domestic disturbance. Sally had a documented history of victimisation in prior relationships and used a knife in self-defence after being assaulted. Jack displayed 20 identified lethality risk factors and rep…
21y · Male·complications of ligature compression of the neck (hanging)
…, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose attempts. Key clinical lessons include: the failure to maintain continuit…
30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …
…ncounter after absconding from hospital. Contributing factors included positional asphyxia, exertion, taser use (deployed three times), and his underlying heart disease. Critical failures included: no ambulance called e…
43y · Male·Hanging
…ttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 2018. He was pla…
asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …
Three linked suicide cases spanning February 2004 to October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital M…
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