38 results for “specialist appointments”
45y · Male·atherosclerotic heart disease
…y clinical lessons: ensure discharge summaries are generated for all released prisoners with outstanding specialist referrals, document reasons for appointment rescheduling, and consider enhanced transition-of-care proto…
57y · Male·Neck compression and hanging
…ement with mental health services remained poor with persistent lack of insight. He refused psychiatric appointments in June-July 2024 but showed no overt suicidal ideation or self-harm. The coroner found no evidence the…
59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…
…ntributed to his death: the treating neurologist (Professor Silburn) failed to arrange timely follow-up appointments despite documenting this plan at discharge, did not ensure the family understood the risks of behaviour…
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
… mental health needs. Critical gaps included no access to dietitian, Aboriginal Health Worker, or timely specialist investigations (cardiac and sleep apnoea despite referrals). Buvidal was commenced with only 1 day on Su…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
…guarding referrals despite multiple opportunities; a psychiatrist's missing progress notes for 11 of 12 appointments in 2020 prevented assessment of clinical deterioration; and the absence of a specialised adult safeguar…
62y · Male·Non-small cell lung carcinoma with metastases
…he medical care provided was otherwise adequate and appropriate. Key lesson: robust systems for tracking specialist follow-up appointments in custodial settings are essential, particularly for serious diagnoses. Electron…
27y · Female·neck compression
…s need better training, clear boundaries preventing perpetrators accessing victim records, and access to specialist family violence advice services rather than managing complex situations alone.
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
…. His mental health issues substantially complicated medical care; he frequently refused investigations, specialist appointments, and interventions. The coroner found his treatment was reasonable under the difficult circ…
27y · Female·hanging, self-inflicted with intention of taking own life
…tal health consultation service available 24/7. Critical failures included: no referral to mental health specialists despite clear policy requirements; no consultation with family despite their presence; no written disch…
5y · Female·Cardiac and respiratory arrest probably connected with embolic stroke
…r recommended formalizing surgical prioritization, implementing documented care plans with written inter-specialist communication, establishing backup appointments, and maintaining surgical waiting lists.
41y · Male·Hanging
…nit provided readily accessible ligature points. Finally, his frustration about unconfirmed psychiatric appointments combined with his untreated, undiagnosed withdrawn mental state likely precipitated his death. The coro…
33y · Male·acute hydrocephalus following ventricular blockage by a colloid cyst
Daniel Johnson, a 33-year-old Aboriginal man, died of acute hydrocephalus caused by a colloid cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months …
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
… across public and private services. Critical failures included: lack of early BPD diagnosis, inadequate specialist clinicians, reliance on medication and hospitalisation rather than evidence-based psychotherapy (DBT/MBT…
19y · Male·Rheumatic heart disease (severe aortic valve regurgitation)
Seth Yeeda, 19-year-old Aboriginal male with rheumatic heart disease from childhood, died in custody from severe aortic valve regurgitation. He had required aortic valve replacement surgery since 2014. In December 2017, …
15y · Male·Electrocution
… 2019 after a paracetamol overdose. Community mental health follow-up appeared appropriate with regular appointments and safety planning. However, significant Child Protection concerns were inadequately managed: practiti…
76y · Male·metastatic prostate cancer with terminal palliative care
…mpassionate, and appropriate healthcare throughout his incarceration, including regular medical reviews, specialist consultations, and high-quality palliative care. One minor issue was identified: a repeat colonoscopy re…
27y · Male·combined drug toxicity (U-47700 and etizolam)
…net purchase. He had chronic spinal pain following a 2012 motor vehicle accident and was managed by pain specialists and his GP with medications including pregabalin, tapentadol, clonazepam, and codeine. Dissatisfied wit…
33y · Male·Complications of methylamphetamine use
…ections and support services were fragmented and under-resourced. After disclosing drug use and missing appointments, contact was sporadic. He experienced a fatal ice binge while living in isolation without coordinated m…
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