53y · Male·Multiple gunshot injuries
…d man with longstanding unresolved childhood trauma, affected by COVID-19 pandemic restrictions, developed acute paranoia and anxiety. Believed people were hacking his devices and tracking him. When school welfare staff…
35y · Male·unascertained - multifactorial cardiorespiratory arrest
…r-old male died in police custody following arrest for dangerous driving and property damage. He displayed acute psychotic behaviour with paranoia, aggression, and 'super-strength' during restraint. Post-mortem examinat…
33y · Male·Exposure to the elements whilst in a mentally unstable state; manner of death Op…
… 33-year-old Aboriginal man, disappeared in late October 1996 from Wyndham, Western Australia, while in an acutely unstable mental state associated with chronic alcohol use disorder, withdrawal symptoms, and possible ha…
62y · Female·ventricular fibrillation associated with congestive cardiomyopathy
A 62-year-old woman detained under the Mental Health Act for acute psychiatric deterioration (psychosis, confusion, paranoia) secondary to anxiety following cardiomyopathy d…
65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists
…ed 2003) and autoimmune thyroiditis. In the week before death, he experienced adverse medication effects (paranoia, panic attacks) after being prescribed antidepressants for worsening depression and anxiety. He presented…
59y · Male·hanging
A 59-year-old man with major depression and psychotic features was lawfully detained under an inpatient treatment order at Noarlunga Hospital's Morier Ward. He was appropriately managed, initially in the high-dependency …
31y · Male·Gunshot wounds to the neck and chest
…ce, substance abuse (methamphetamine, cocaine), and untreated mental health issues including drug-induced paranoia. Despite repeated directions from his parole officer to obtain a mental health plan after release, he fai…
74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…
On 9 November 2018, Hassan Khalif Shire Ali committed a premeditated ISIS-inspired terrorist attack in Bourke Street, Melbourne, using an improvised explosive device in his vehicle followed by a knife assault. He fatally…
60y · Male·Mixed drug toxicity
A 60-year-old man with schizophrenia and depression presented to Maroondah Hospital ED with acute psychotic symptoms after stopping his antipsychotic medication (trifluoperazine) due to manufacturer disco…
26y · Male·hanging
…ervation, this was not implemented. Key clinical lessons: suicide risk assessment in custody must consider acute behavioural changes, expressed fears, and relationship crises even without prior history; inmates under pe…
35y · Male·unascertained - multifactorial: underlying ischaemic heart disease, drug intoxic…
… unascertained causes during police arrest at Bellbrae on 11 January 2019. He presented to The Alfred with acute paranoia, hallucinations and agitation following synthetic cannabis use, and was discharged after assessme…
36y · Male·undetermined (possibly ethylene glycol poisoning; possibly natural cause such as…
A 36-year-old man with acute psychotic illness absconded from Ryde Hospital Emergency Department on 3 August 2013 after refusing oral a…
37y · Male·multiple injuries in a man with methylamphetamine effect (suicide by jumping fro…
Simon John Rowe, a 37-year-old man with a history of drug use and imprisonment, died by suicide on 12 April 2012 after deliberately jumping from a 12th-floor hotel window during a police siege. He had smashed the window,…
21y · Male·undetermined causes, in the course of being restrained by members of the NSW Pol…
Roberto Laudisio Curti, a 21-year-old Brazilian, died on 18 March 2012 during police restraint in Sydney after consuming LSD which induced a psychotic state. After a convenience store incident was misclassified as an arm…
34y · Male·gunshot injuries to the torso
…nia, was fatally shot by police on 1 May 2020 after stabbing multiple people at a shopping centre while in acute psychosis. He had been non-compliant with depot antipsychotic medication for four months following his dis…
33y · Male·sharp force injuries of the neck
…f) was not communicated to senior decision-makers. Key clinical lessons include the challenges of managing acute mental health crises with substance intoxication, importance of information-sharing in triage decisions, a…
84y · Female·septicaemia secondary to septic arthritis of the left knee
An 84-year-old woman presented to hospital with acute left knee swelling and pain. Initial assessment at Ashford Hospital ED reasonably excluded septic arthriti…
25y · Male·hanging
Logan Brown, a 25-year-old man on home detention bail, died by hanging. He had a complex psychiatric history including borderline personality disorder, polysubstance use disorder, and chronic suicidal ideation dating fro…
40y · Male·unknown
Richard Ken Roe disappeared on 2 November 2016 from Lake Bennett, NT, and is presumed deceased. He was last seen near his abandoned vehicle, reportedly having car trouble. The coronial investigation examined two main hyp…
30y · Male·Exsanguination due to self-inflicted multiple stab and incised wounds
…h antipsychotic medication with variable compliance. In the weeks before death, he experienced escalating paranoia and delusional ideation, including paranoid beliefs about being persecuted. He presented to hospital on 8…
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