621 results for “mental health concerns”
29y · Male·Mixed drug toxicity (heroin and methamphetamine)
A 29-year-old man with a history of heroin and methamphetamine addiction died from mixed drug toxicity. He had suffered a work-related back injury leading to opioid dependence, complicated by anxiety and panic attacks. A…
54y · Male·Unable to be ascertained. Multiple contributing factors identified: arrhythmogen…
54-year-old man with schizophrenia died after acute mental health crisis during police response. Contributing factors included: arrhythmogenic cardiomyopathy (undete…
31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…
…ic admission despite a formal request; failure to nominate or involve his father as designated carer under Mental Health Act 2007 despite the father having been contacted at admission; sparse documentation of key clinica…
Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …
…iam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observation during the f…
30y · Male·asphyxia due to hanging (suicide)
…yan died by suicide via hanging in July 2009. Multiple systemic failures preceded his death. The Community Mental Health Service failed to communicate Mr Ryan's past suicide attempt to the hospital and did not inform tre…
22y · Male·ligature compression of the neck (hanging)
…nosis despite a comprehensive 2016 assessment and 20 times higher suicide risk with FASD, (2) insufficient mental health resources, (3) significant understaffing due to COVID-19, (4) staff lack of FASD training and risk …
47y · Male·Bronchopneumonia on a background of methadone and benzodiazepine use
…ents. The coroner was unable to find the death preventable but identified significant clinical management concerns.
29y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
…e suggested possible suicidal intent, this could not be confirmed. The coroner highlighted ongoing safety concerns on this stretch of highway, where multiple head-on collisions have occurred despite a duplication project…
58y · Male·Heroin toxicity
…g morning. Clinical lessons include: coordinating care between multiple prescribers (GPs, pain management, mental health) to prevent polypharmacy and drug-seeking behaviours; recognising that patients with established ad…
15y · Female·Unknown - insufficient evidence for finding
This coronial finding concerns the disappearance and suspected death of Katrina Bohnenkamp, a 15-year-old girl in state care who was las…
Male·Gunshot wounds to the head
… of prior suicidal behaviour. After Noah's boating injury (September 2022), Wayne stopped medications. His mental health deteriorated by May 2023; Dr C. restarted treatment but couldn't escalate to acute services due to …
36y · Male·Hanging
…psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3 days) had classified him as low suicide risk (S4, P3 ratings). While he denie…
37y · Male·self-inflicted gunshot wound to the head and neck
…etention mechanisms, and should not have been issued for operational use. Additionally, Lothian had sought mental health assistance but declined to sign the CSNSW Psychology Services consent form due to confidentiality c…
Ligature compression of the neck (hanging) in 12 cases; one open finding
…ting factors included intergenerational trauma, exposure to domestic violence and alcohol abuse, untreated mental health conditions, poor physical health (failure to thrive, recurrent infections), and inadequate access t…
38y · Male·Hanging
… point for a ligature. The coroner found the At-Risk procedure was properly applied and noted that family concerns raised shortly before death did not specifically mention suicidal ideation. Key lessons include maintaini…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
…aqi, 41) hanged himself on 15–16 November despite clearly expressing depression, trauma, and deteriorating mental health; mental health protocols were not followed, his diagnosis was incorrect (Adjustment Disorder rather…
Female·self-inflicted death
…sons: (1) Complete medical and psychological histories must be shared with treating clinicians—Emily's new healthcare providers lacked prior reports; (2) Schools must receive written information about children's mental h…
27y · Male·Mixed drug (methylamphetamine and clozapine) toxicity
…nial of funeral leave, no consideration was given to offering KT support through cellmate placement. While mental health treatment was generally adequate within custodial constraints, system failures around pathology fol…
29y · Male·ligature compression of the neck (hanging)
…octor admission assessments should occur within the mandated 90-day timeframe to allow patients to discuss mental health and medical concerns. While the coroner identified several missed opportunities, no adverse finding…
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, …
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