368 results for “substance use disorder history”
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…
26y · Male·Craniocervical injuries following a train collision (pedestrian)
Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…
44y · Male·Heroin toxicity in the setting of ischaemic heart disease
…om prison. He had been granted parole despite assessments recommending against it, citing poor compliance history. Within hours of release, he obtained heroin and used it, likely with reduced tolerance after prison abst…
26y · Male·shotgun wound of the chest
Nicholas Aaron Scott, a 26-year-old prisoner with a history of self-harm, escaped from Royal Hobart Hospital on 2 January 2023 while under correctional officer super…
27y · Female·Hanging
Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020…
24y · Female·Exsanguination from injuries sustained while attempting to climb from a height i…
Phoebe Handsjuk, a 24-year-old woman with a history of depression, anxiety, and alcohol abuse, was found deceased in the refuse room of her apartment buildin…
34y · Male·Incision/stab wound to the neck
A 34-year-old male remandee died by self-inflicted neck wound while in custody at Metropolitan Remand and Reception Centre. He had been discharged from Risk Intervention Team management following a self-harm incident 7 d…
25y · Male·Hypoxic ischaemic brain injury due to hanging
… rather than health-based interventions. Mental health assessment did not occur despite his S4 (self-harm history) rating. While staff made vigorous resuscitation efforts, the coroner found the decision to address escap…
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 psych…
Male·Multiple injuries due to train over-run (suicide by train)
…tempts, and parental concerns. Dr D.' decision lacked critical information about Liam's suicidal ideation history and absconding attempts because Dr B. (junior doctor) did not adequately brief him, and Dr D. did not rea…
36y · Male·Multi-organ failure complicating injecting drug use
A 36-year-old man with a 13-year history of schizophrenia and substance abuse was admitted involuntarily to a psychiatric unit on 15 September 201…
0y · Female·Unascertainable
…psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child was found unresponsive after co-sleeping with her father in a warm bedroom. Multiple SIDS risk f…
38y · Male·hanging
Shane Tuck, an elite AFL player (2004-2013) and professional boxer (2015-2017), was found deceased by hanging on 20 July 2020. Post-mortem neuropathology confirmed severe stage III chronic traumatic encephalopathy (CTE).…
25y · Male·opiate toxicity (heroin overdose)
Andrew Nicholas Petrelis, a witness protection program participant, was found dead in his Caloundra apartment on 11 September 1995 from opiate toxicity (heroin overdose). He had relocated from Western Australia to Queens…
42y · Male·Incised injury to the neck resulting in exsanguination and air embolism
…d clinical assessment recommending acute assessment unit admission, he remained on a waiting list and was housed in a mainstream unit with unrestricted access to razor blades. The coroner found that while psychiatric ca…
21y · Male·complications of ligature compression of the neck (hanging)
…qi-born man in immigration detention, 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 includ…
31y · Male·hanging
… Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm history. Following his psychiatric assessment on 20 February 2017, he was never reviewed by a psychiatrist during…
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…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
…clinical lessons: (1) Multiple unmet requests for antidepressant medication despite documented depression history and clear clinical indication—a significant departure from reasonable care standards; (2) Failure to resc…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
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