38y · Male·The combined effect of Methylamphetamine Toxicity and prolonged restraint in a p…
…s devastating cardiovascular effects and the importance of recognising drug-induced psychosis and excited delirium in emergency management.
30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology
… severe behavioural disturbance resistant to anti-psychotic medication, progressing to medication-induced delirium. He was treated with multiple anti-psychotic agents, including an inadvertent long-acting injection, lead…
23y · Male·Unascertained
… and biochemical derangements from prolonged struggling, combined with mild coronary artery narrowing and possible underlying brain pathology, may have contributed. The coroner noted the family should have been informed …
41y · Male·multi-organ failure and staphylococcal septicaemia following pulmonary and aorti…
…cal lessons: early recognition of sepsis severity, appropriate use of mental health legislation for acute delirium secondary to medical illness, and timely escalation to cardiothoracic surgery. Vaccination of at-risk wor…
31y · Male·Status epilepsy secondary to cerebral cavernoma
…tus epilepticus triggered by an unknown cause (possibly nicotine from recent vaping). While in post-ictal delirium, he was perceived as aggressive/intoxicated. Police and paramedics responded, using physical and mechanic…
61y · Male·Pneumonia
Kenneth Morrison, a 61-year-old man with Down's syndrome, dementia and multiple comorbidities, died from pneumonia following hospitalisation at Casey Hospital in March 2008. Community Residential Unit (CRU) carers raised…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
…n, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropriately identified possible septic arthritis and contacted orthopaedic registrar Dr N., who advised withholding antibiotics pending j…
23y · Male·Acute cardiac arrhythmia in 3,4-methylenedioxymethylamphetamine (MDMA) intoxicat…
Tristan Naudi, 23, died from acute cardiac arrhythmia during MDMA intoxication while being restrained prone at hospital. Police appropriately placed him in a police vehicle after finding him violently agitated at home. A…
89y · Male·unascertained - natural causes
Harold Edward Burgess, aged 89, died in Port Phillip Prison's medical unit from unascertained natural causes following a fall on 6 November 2022 that resulted in cervical spine fractures. He was deemed unsuitable for sur…
32y · Male·sudden cardiac arrhythmia
…-down facility. The underlying cause of the fatal arrhythmia could not be definitively determined, though possible contributors included prior antipsychotic medication exposure (long QT syndrome risk) or the pituitary tu…
63y · Male·cerebral infarction
…on suggested haloperidol, combined with respiratory compromise from motor neurone disease and post-stroke delirium, may have contributed to death. Key lessons: inappropriate use of antipsychotics as sedatives in dementia…
75y · Male·pneumonia and head injury from fall
Peter Harris, aged 75, was admitted with behavioural disturbance and hyponatraemia (low serum sodium of 124 mmol/L). Initial clinical assessment did not identify falls risk. After 4 days, he fell backwards suddenly while…
55y · Male·Cardio-respiratory arrest due to mixed prescription drug sedation (clozapine and…
…n saturation monitoring with pulse oximeter, insufficient respiratory rate monitoring, failure to exclude delirium as cause of agitation, vague observation orders, and absence of specialist respiratory input. The coroner…
28y · Male·Bronchopneumonia caused by metastatic lung cancer (adenocarcinoma)
Damien Hughes, a 28-year-old Aboriginal man serving a prison sentence, died from bronchopneumonia caused by metastatic lung adenocarcinoma. He presented with a two-week history of chest swelling in April 2012 and was pro…
56y · Male·hypothermia
…ound hypothermic and unconscious at home and died. The coroner found the ED assessments failed to address possible acute alcohol withdrawal—a serious medical event with multiple complications. Earlier welfare checks afte…
Male·Combined effects of hypothermia and incised wounds to the neck
Edward Ronald Vuissoz, a boarding house resident at Kings Cross, Sydney, was reported missing on 30 July 2012 after not being seen for several days. His body was discovered on 8 August 2012 in thick scrub at Balls Head R…
80y · Male·Drowning
…treatment was appropriate, the observation error created a window where earlier detection might have been possible. Key clinical lessons include the importance of accurate documentation of observation orders, ensuring co…
39y · Male·coronary atherosclerosis
A 39-year-old Aboriginal man died from coronary atherosclerosis after police responded to reports of strange and agitated behaviour. His mother and family had requested police assistance; he appeared to be experiencing a…
65y · Female·Status epilepticus complicating cerebral palsy
…ions; recurrent aspiration pneumonia suggests need for specialist input (speech pathology, nutrition) and possible dietary modification or alternative feeding routes earlier in the disease course.
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
Paquita Goldberg, an 87-year-old woman with dementia, BPSD, and paranoia, died from intentional inhalation of tissue paper while admitted to Baringa aged psychiatry unit under a Mental Health Act order. Over 7-8 February…
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