402 results for “suicide risk high”
30y · Male·Hanging
…er 2017. Mr Stachor had a documented history of self-harm attempts and had previously been placed under the High Risk Assessment Team (HRAT) regime during an earlier 2017 remand. Despite clear indicators of mental health…
60y · Female·hanging
…ented plan to manage anticipated pain recurrence post-infusion, or evidence that clinicians understood this risk. The coroner identified absence of evidence-based guidelines for low-dose ketamine administration, follow-u…
73y · Female·neck compression by ligature
…ficer unfamiliar with psychiatry, and the psychiatric registrar. The clinical team assessed her as moderate risk of self-harm without access to this information. Despite her longstanding suicidal ideation history, risk a…
30y · Male·hanging
…ife. He was discharged after approximately 4 hours without adequate assessment of benzodiazepine withdrawal risks, without involvement of family in discharge planning despite clear parental concerns, and without a docume…
61y · Male·asphyxial death due to hanging
…given the complex presentation. However, a root cause analysis identified systemic deficiencies: inadequate risk assessment documentation, absence of formal leave plan, no safety plan for the patient or carer, absence of…
31y · Female·mixed drug toxicity (propoxyphene, fluvoxamine, and alprazolam)
… 70 minutes while waiting for medical review. Key clinical lessons: patients with self-harm history require higher suspicion for undisclosed overdose; patients requiring barouches in ED must receive documented, frequent …
33y · Male·hanging
…r four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attempt in 2016. Clinical lessons include: the PSP/SME monitoring system adequately supported him, but th…
73y · Male·Neck compression in the circumstances of hanging
…ing at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statements, minimal engagement with staff, and time spent isolated in his room. Key…
31y · Female·organ failure due to anorexia nervosa
Chloe Tupper died of organ failure due to severe anorexia nervosa at age 31. She had suffered from this illness for 17 years since age 14, receiving multiple episodes of hospital-based refeeding that never achieved lasti…
48y · Male·Hanging
…ng, though the initial response (24-27 April) generally complied with Victoria Police policies. Mr Sparke's risk remained high given his stated suicidal intent and active evasion of police. He was found deceased in his a…
30y · Female·Hypoxic brain injury due to mixed drug toxicity (vecuronium and atropine self-in…
…) emergency medication trolleys in Ward B4 were inadequately secured. The coroner found the death was not suicide but recreational drug-seeking behavior reflecting institutional restrictions and inadequate psychiatric c…
45y · Male·Stab wound to the chest, self-inflicted
Shane Lockwood, a 45-year-old man with chronic schizophrenia, died by self-inflicted stab wound in April 2009, approximately two months after discharge from psychiatric hospital on a Community Treatment Order. He was dis…
51y · Male·Stab wounds to the chest
A 51-year-old man with documented mental health issues including psychosis, paranoia, and delusions died from self-inflicted stab wounds during a police siege at his mother's home. He had breached a domestic violence ord…
49y · Female·Doreen Langham: combination of spleen injury and effects of fire; Gary Hely: eff…
Doreen Langham was killed by her intimate partner Gary Hely in an intimate partner homicide-suicide on 22 February 2021 in Queensland. The death was preceded by extensive domestic violence including physic…
23y · Male·Effects of fire
…rral; (2) observations at predictable 30-minute intervals were suboptimal—variable timing is preferable for high absconding risk patients; (3) a known environmental risk (easily scalable courtyard fence) was not addresse…
19y · Male·Hanging
…esign. No mental health assessment for an isolated vulnerable young inmate was conducted after he entered a high-risk situation.
22y · Male·Hanging
…uire more frequent psychiatrist review (the deceased was prioritized as 'routine' when he should have been 'high priority'); medication changes should not be made without assessing the patient; and prison is unsuitable f…
29y · Male·ligature compression of the neck (hanging)
…dering at 7:15-7:30 am); (3) failure to implement the 'Did Not Wait' policy requiring follow-up of moderate/high-risk mental health patients; (4) prescribing antipsychotics without medical review; (5) inadequate mental h…
35y · Male·Choking due to impaction of soap in airway
…ation died from choking on a bar of soap while in involuntary psychiatric care. He had attempted multiple suicides previously. Clinical lessons include: (1) periodic observations conducted through closed doors may miss …
46y · Male·complications of ligature compression of the neck (hanging)
…HRSO Act) following release from prison in February 2022. Despite restrictions designed to manage community risk, Mr STW received minimal psychological or substance abuse support despite these being identified as primary…
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