390 results for “mental health deterioration”
53y · Female·Combined drug toxicity (propranolol and insulin)
…spite comprehensive assessments by multiple psychiatrists and the CAT team who identified her clinical deterioration, dependency and impaired judgment, she did not meet involuntary Mental Health Act criteria. Clinicians…
77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)
A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
…a, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February 2013, she experienced escalating distress, disclosed prior sexual trau…
27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…
…rocedural safety, and inadequate monitoring of access to alcohol and drugs that precipitated his acute deterioration.
51y · Female·Ischaemic heart disease
Pauline Margaret Dodd, 51, died of ischaemic heart disease at Sir Charles Gairdner Hospital on 4 March 2014. She was an involuntary psychiatric patient with long-standing bipolar affective disorder, complicated by childh…
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
…cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 …
19y · Female·combined drug effect and myocarditis
…ing despite haloperidol's QT-prolonging effects. Inadequate observations at Graylands failed to detect deterioration. Clinical lessons: verify drug concentrations against source ampoules, clearly document medication err…
22y · Male·Hanging
…ent, no family involvement in monitoring despite available options, inadequate follow-up on a pre-existing mental health condition, and insufficient product labelling accessible to patients.
20y · Male·Multiple injuries from fall from height
… panic attacks, with correctional staff using demeaning language rather than therapeutic responses. Better mental health support, least-restrictive placement options, and proper RIT procedures could have prevented this t…
28y · Male·hypoxic encephalopathy secondary to hanging
…pital. He had been admitted on 8 November 2003 after separation from his de facto wife triggered acute deterioration. He was discharged on weekend leave on 21 November and returned early on 22 November distressed about …
43y · Female·neck compression due to hanging
A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…
41y · Male·sympathomimetic syndrome
…ned earlier medical assessment may have been beneficial, though outcome remained uncertain given rapid deterioration.
39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…
…ss via adrenergic response and muscle tetany; (4) pre-hospital resuscitation was delayed despite clear deterioration; (5) his severely narrowed coronary arteries and enlarged heart meant he was at imminent risk of sudde…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
…rist Dr T. and physician Dr E., managed a complex case balancing her autonomous wishes against medical deterioration. After involuntary admission on 13 January when cognitive impairment interfered with treatment decisio…
24y · Male·plastic bag asphyxiation
…ening, guards conducting five nightly cell checks between 20:25 and 06:35 hours failed to identify his deterioration. Prison Officer Rowley at the 06:35 unlock also failed to confirm Hayes was alive. The coroner found t…
77y · Female·Venlafaxine toxicity in a woman with severe renal impairment and depression
77-year-old woman admitted to psychiatric ward with severe depression and catatonic features. Despite documented severe renal impairment and dehydration on admission, no medical review occurred over the weekend prior to …
35y · Male·acute vomit aspiration in a man with acute large intestine obstruction (severe m…
Stephen Michael Kell, a 35-year-old man with treatment-resistant schizophrenia, died at Graylands Hospital from acute vomit aspiration in the setting of acute large bowel obstruction and clozapine-induced gastrointestina…
40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…
…zures, medication non-compliance, 72-hour sleep deprivation); (2) inappropriate application of a community mental health management plan to a custodial setting, which recommended avoiding detention despite manifestations…
24y · Male·Strangulation by hanging
…resaw suicide as a consequence, the reduction of leave—communicated abruptly—directly precipitated the deterioration that led to his death.
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