621 results for “mental health concerns”
64y · Female·fatal cardiac arrhythmia in a lady with obstructed sleep apnoea, obesity and suf…
…ted with haloperidol and clonazepam. Despite recording hypoxia (oxygen saturation 93%) and requiring supplemental oxygen overnight, she was transferred to an aged-care psychiatric ward (Banksia Ward) the following aftern…
47y · Female·Multiple injuries from being struck by a train; death determined to be suicide
…ic care was inadequate, with serious miscommunications between Swan Valley Centre and Inner City Community Mental Health Service about whether depot olanzapine would be provided; (2) there was no coordinated multidiscipl…
36y · Male·gunshot wounds to the head and pelvis
…hots, fatally wounding him. The coroner found the shooting lawful under self-defence provisions. However, concerns were raised about SERT decision-making regarding the intercept location and timing, potential confusion a…
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
Male·Multiple: ligature compression of neck (hanging) in four cases; incised injury t…
…e coroner identified multiple systemic failures including: inadequate Prison Counselling Service (PCS) and mental health staffing despite known high prevalence of mental health disorders (40% with mood/anxiety disorders,…
28y · Female·methadone toxicity
A 28-year-old woman with a history of mental illness and substance use disorder died from methadone toxicity five days after recommencing methadone mai…
26y · Female·multiple injuries sustained as a result of being struck by a motor vehicle on th…
A 26-year-old woman with schizo-affective disorder, detained under the Mental Health Act, absconded from a psychiatric hospital and was fatally struck by a vehicle on a freeway. Clinic…
43y · Male·Hanging
…r covered by bedding would have been difficult. The death highlights the challenge of identifying emerging mental health concerns in custodial settings when critical observations are made only by cellmates and not formal…
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
…homeless and unwell, he was placed at St Bartholomew's hostel on the understanding he would self-medicate. Mental health staff restricted medication amounts initially due to concerns about impulsive overdosing, but on 1 …
21y · Male·upper airway obstruction and plastic bag asphyxia
…rom S2 to S3 on 27 September 2007 without considering the isolating prison environment known to worsen his mental state. Critical failures included: poor information sharing between psychiatric services, correctional sta…
36y · Male·Complications of morbid obesity, including cardiac enlargement, aspiration of ga…
…unity. The preventable element was delayed relocation to appropriate higher-level care despite documented concerns from staff.
23y · Male·hanging
…the treating psychiatrist/registrar did not review him post-transfer as required within 12 hours under the Mental Health Act; staff noted concerning door-closing behaviour but did not escalate for psychiatric reassessmen…
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple…
42y · Female·salt water drowning
…ssion with psychotic features following a recent suicide attempt, and was appropriately detained under the Mental Health Act. The coroner identified critical failures in implementation of care: (1) Dr K.'s request for 'c…
35y · Male·hanging
…after his suicide risk rating was rapidly downgraded from S1 to S4 over four days. Both men had documented mental health concerns and history of suicide risk. Key clinical lessons include: risk assessments are ephemeral …
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
…nadequate risk assessment and planning by police before and during the operation; miscommunication between mental health services and police about the sword possession and staffing availability; premature and unnecessary…
58y · Female·Pentobarbitone toxicity
…ntrols, improved product labelling, better communication of safety information, and enhanced education and mental health support within the veterinary industry.
49y · Male·dilated cardiomyopathy due to chronic alcoholism
…, and evidence of heart disease. The coroner found no evidence of traumatic injury despite initial family concerns about neck marks, which were attributed to post-mortem insect predation. Notably, the coroner found that …
59y · Male·pulmonary thromboembolism due to left deep calf vein thrombosis
… clonazepam, valproate, temazepam) for agitation and behavioural management. Some nursing staff expressed concerns about over-sedation, but expert psychiatric review found medication doses appropriate and clinical manage…
40y · Male·compression of the neck due to hanging
Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance …
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