29 results for “undiagnosed mental health issues”
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
…onality disorders, and multiple serious physical conditions including COPD, ankylosing spondylitis, and undiagnosed pancreatic adenocarcinoma, died from bronchopneumonia. He was a long-term involuntary psychiatric inpat…
37y · Male·Hanging
…ors: marital breakdown, financial hardship including truck repossession, family estrangement, and physical health issues (post-MI with cardiac surgery). Police officers who attended the property at 12:30pm conducted a ri…
31y · Male·Gunshot wounds to the neck and chest
…ome in Queensland. He had a history of violence, substance abuse (methamphetamine, cocaine), and untreated mental health issues including drug-induced paranoia. Despite repeated directions from his parole officer to obta…
28y · Male·toxicity to heroin
…ose death in 1999. No medical intervention was sought or available during his fatal overdose. Key systemic issues identified included: toilet design that prevented timely access and rescue, failure of CCTV surveillance s…
41y · Male·Hanging
…le system failures: psychiatric assessment referrals were not acted upon despite evidence of deteriorating mental state and suicidal ideation; the downgrade of his suicide watch rating on 20 March was based on a non-clin…
39y · Male·Strychnine toxicity
…Kingaroy Hospital was timely and reasonable. However, key clinical lessons include: failures in completing health/medication assessment forms at watchhouse admission despite signs of medication effects; lack of systemati…
80y · Male·Drowning
…entional suicide. The death was likely due to accidental drowning in confusion, possibly complicated by undiagnosed cardiac disease.
41y · Male·Cardiomegaly in a man with WHO Class III obesity
… poor follow-up after medical episodes. The coroner found multiple opportunities for improvement in prison healthcare delivery, particularly regarding Aboriginal prisoners' access to culturally safe, continuous, equivale…
75y · Female·Plastic bag asphyxia in the setting of blunt force head injury
…e professionals in September 2018 and July 2019 were adequate, but identified a critical systemic failure: health professionals incorrectly believed EW needed a formal dementia diagnosis before referral to dementia suppo…
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