391 results for “psychiatric medication management”
35y · Male·Choking due to impaction of soap in airway
A 35-year-old man with treatment-resistant depression and complex psychiatric presentation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted…
37y · Female·open finding - undetermined
…al health follow-up with no ongoing therapy or strong therapeutic relationship established. She stopped psychiatric medication in 2015 during pregnancy and did not resume it after a subsequent miscarriage in November 20…
30y · Male·external neck compression due to hanging
…, antisocial personality disorder) and substance abuse, died by hanging four days after presenting to a psychiatric emergency centre with self-inflicted wrist lacerations and expressing suicidal intent. A psychiatric re…
55y · Female·Multiple drug toxicity due to combination of alcohol and benzodiazepines (oxazep…
… involving alcohol, oxazepam (toxic level), temazepam, and promethazine. Her GP, Dr B., prescribed these medications weekly for seven years without in-person clinical review, despite signs of poly-substance dependence an…
Male·neck compression due to hanging
…ught in by police under Mental Health Act section 57 but were not detained and discharged after minimal psychiatric evaluation. Robert Campbell (53) was assessed by an inexperienced locum resident who noted high risk an…
71y · Male·Sepsis due to bronchopneumonia and sacral ulcer
Mr John Knight, aged 71, died from sepsis secondary to bronchopneumonia in a psychiatric inpatient unit after five months admission for frontotemporal dementia management. His complex behaviou…
65y · Male·hypoxic ischaemic encephalopathy complicating hanging
…he next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included: misdiagnosis of the underlying steroid-induced syndrome, failure to…
50y · Male·Hanging
A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary…
57y · Female·right bronchopneumonia following hypoxic brain damage secondary to cardiac arres…
A 57-year-old woman with chronic schizophrenia and non-insulin dependent diabetes was admitted to a psychiatric ward after detention under the Mental Health Act. She was found in cardiac arrest on 8 December 2001 an…
60y · Male·Drowning; elevated blood ethanol level
…holas Lobo, aged 60, died by drowning with elevated blood alcohol (0.21%). He was discharged from acute psychiatric inpatient care to a rehabilitation facility on a Community Treatment Order after recent diagnosis of sc…
30y · Male·head and chest injuries sustained in a fall from a height
…order, died from head and chest injuries sustained in a fall from height on 24 September 2007. He had a psychiatric review on 20 September 2007 with Dr M., who assessed him as non-suicidal, reviewed his medications (Lit…
25y · Female·Ligature Compression of the Neck (Hanging)
…f her death, she expressed suicidal ideation to multiple staff members, but no one initiated the At Risk Management System (ARMS), a protocol designed to prevent self-harm. Critical information about her distress was not…
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
…; under-resourcing of community teams; bed pressure driving early discharge decisions; and insufficient psychiatric review prior to discharge. Both deaths were preventable with more assertive detention, adequate medicat…
31y · Male·Hanging
…nging in custody at MRRC on 7 July 2018, five days after being cleared from Risk Intervention Team (RIT) management. The coroner found it would have been more appropriate for him to remain on RIT management on 10 June, 1…
40y · Male·respiratory failure due to Adult Respiratory Distress Syndrome (ARDS)
…-old man with treatment-resistant schizophrenia and documented severe adverse reactions to antipsychotic medications, was admitted to Royal Adelaide Hospital from psychiatric detention for anaemia requiring blood transfu…
42y · Male·Multiple injuries sustained in motor vehicle crash
…ment Order died in a single-vehicle motor crash in rural Western Australia. He had poor insight, chronic medication non-adherence, and a pattern of acute relapses requiring repeated hospitalisations. In late May 2015, de…
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
…ental Health Act detention for acute psychosis. Critical clinical lessons include: (1) her antipsychotic medication was inadequate despite florid psychosis; (2) she required one-to-one nursing observation but was managed…
32y · Male·unascertained; most likely exposure after walking in bushland
Jason Marcus Lawson, a 32-year-old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on…
47y · Female·Mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol…
…cohol use disorder and chronic conditions, died from mixed drug toxicity involving multiple prescription medications. She was admitted to Brunswick Private Hospital in October 2021 with a fractured hip and psychiatric re…
54y · Female·unascertainable
…luding bizarre behaviour, religious ideation, and visual phenomena, but was not prescribed antipsychotic medication. She left the hospital voluntarily at 6:19am on 21 February 2011 without being discharged. Her vehicle w…
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