30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
Candice Mackenzie Wallace-Mohlmann, a 30-year-old woman with chronic schizophrenia and substance abuse history, died from hypoxic brain injury caused by self-injection of vecuronium and…
34y · Female·Mixed drug toxicity (ethanol, methadone, diazepam and risperidone)
Cassilla Ellen Dooley, a 34-year-old woman with chronic mental illness and substance dependence, died from mixed drug toxicity involving ethanol, methadone, diazepam, and risperidone at a supported housing facility. She …
28y · Female·combined drug toxicity (heroin and prescribed psychiatric medications)
Priscilla Stephenson, a 28-year-old Aboriginal woman with longstanding mental illness and polysubstance abuse, died from combined drug toxicity (heroin plus prescribed psychiatric medications) shortly after discharge fro…
Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…
Five former psychiatric patients of Alma Street Centre (part of Fremantle Hospital) died between March 2011 and March 2012. Two died by suicide within 24 hours of discharge; one disappeared and was found deceased; one ab…
Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…
Five patients of Alma Street Centre's psychiatric unit died within 12 months (2011-2012). Three died by suicide within 24 hours of discharge; one disappeared and died; one absconded while detained and died. Clinical less…
24y · Female·multiple injuries from jumping off Bulla Road overpass onto Tullamarine Freeway
Renee Treen, aged 24, died by suicide from the Bulla Road overpass while an involuntary psychiatric patient. Critical failures included: inadequate assessment of suicide risk (prior freeway-adjacent behaviour not weighte…
Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…
Five young to middle-aged people with serious mental health conditions died by suicide within 12 months (March 2011 to March 2012) while under care from Alma Street Centre mental health services in Western Australia. Rub…
Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…
Five psychiatric patients from Alma Street Centre (Fremantle Hospital) died by suicide within 12 months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health ser…
Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…
Five young adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, M…
63y · Female·Multiple stab wounds to neck and chest
Voula Delios, a 63-year-old grocer in Hobart, was fatally stabbed by Daryl Cook on 23 July 2016, one day after his release from prison. Cook suffered from serious untreated mental illness, evidenced by extensive prison r…
38y · Male·acute cardiac arrhythmia in a man with cardiomegaly, focal coronary atherosclero…
Russell Brockliss, a 38-year-old Aboriginal man with severe treatment-resistant schizoaffective disorder and significant cardiovascular risk factors (obesity, smoking, focal coronary atherosclerosis), died from acute car…
52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…
Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries su…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suic…
41y · Female·neck compression
…from neck compression between 12-14 February 2016. She was in a relationship with LM, who had paranoid schizophrenia, substance abuse issues, and a history of violence. Following a family violence incident on 17 January…
21y · Male·upper airway obstruction and plastic bag asphyxia
Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable du…
75y · Female·pyelonephritis and pneumonia
Molly Jessie Smith, a 75-year-old woman with longstanding severe mental illness, died of pyelonephritis and pneumonia on 16 August 2009. She had been in state psychiatric care continuously for 53 years. During her final …
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-immolate due to distress about power cuts at h…
Unknown·Ruby Nicholls-Diver: ligature compression of neck (hanging); Carly Jean Elliott:…
Five psychiatric patients of Alma Street Centre died between March 2011 and March 2012. Two (Ruby Nicholls-Diver and Anthony Edwards) died within 24 hours of discharge; two (Carly Elliott and Michael Thomas) died shortly…
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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