621 results for “mental health concerns”
15y · Male·compression of the neck consistent with hanging
…ar 10, died by hanging while alone at home on 9 October 2010. He had been referred to Child and Adolescent Mental Health Services (CAMHS) in December 2009 and saw various therapists, primarily social worker Vina Hotich f…
36y · Male·Acute on Chronic Myocardial Infarction
…d to be a seizure; cellmates observed difficulties but did not alert guards due to fear of waking him and concerns about his potential reaction. He suffered a fatal heart attack around 5:30–5:45 am and could not be reviv…
62y · Male·cardiac arrhythmia secondary to prolongation of the QT interval
… disorder and hypothyroidism, died of cardiac arrhythmia secondary to QT prolongation while an involuntary mental health inpatient. He had a known history of non-compliance with thyroxine medication. Thyroid function tes…
44y · Male·Hanging
Colin Wayne Blair, a 44-year-old Aboriginal man with a history of mental illness and substance use, died by hanging in the High Dependency Unit of Brisbane Correctional Centre on …
60y · Male·Neck compression secondary to hanging
…k assessment, and relied on demeanor to conclude he was 'not at risk'—despite him expressing reputational concerns. His condition deteriorated significantly after release from custody. The coroner found police actions fe…
50y · Male·Mixed drug toxicity (propofol, codeine, diazepam)
…ound dead at home on 12 May 2013. The coroner determined he died by suicide. Key clinical lessons include: healthcare workers with access to potent anaesthetic agents represent a high-risk occupational group; 15 of 15 Vi…
56y · Male·Asphyxia
Stuart Cecil Ford, a 56-year-old prisoner at Wolston Correctional Centre, died by asphyxiation when he intentionally placed a plastic bag over his head on 16 January 2010. He had a history of adjustment disorder with anx…
54y · Male·compression of the neck due to hanging
Anthony Lanzafame, a 54-year-old remand prisoner, died by hanging in his single cell at Adelaide Remand Centre on 24 May 2016. He had been on remand for 17 months facing murder charges and was undergoing trial when he di…
48y · Female·Head injuries
…inical context is limited—the finding focuses on circumstances rather than medical management. Key lesson: healthcare providers (Family Relationship Centre mediator, psychologist) should screen for subtle coercive and co…
0y · Female·Sudden infant death syndrome or asphyxiation due to co-sleeping or overlaying
…ld protection assessment addressing totality of risks; collaborative practice between child protection and health services; and counselling families on safe sleep practices. The case highlights failures to sufficiently w…
30y · Male·Unable to be ascertained
… and coordinated National Park searches were delayed until 5 and 11 February respectively, despite family concerns. The coroner found non-compliance with SOPs regarding shift handover, officer designation, and Missing Pe…
54y · Male·Respiratory failure due to aspiration pneumonia and acute autonomic and sensory …
…and progressive neurological decline. The coroner found his treatment generally appropriate but noted two concerns: poorly controlled diabetes at Glenside Hospital (unrelated to his death) and critical failure to recogni…
20y · Male·Ligature compression of the neck (hanging)
…arina Prison on 2 September 2004. He had been identified as at chronic risk of self-harm and was receiving mental health support. Critical failures in his care included: (1) reception staff at Hakea Prison failing to ide…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
… include the importance of early recognition of functional decline, regular GP engagement in patients with mental health conditions, proactive assessment for pressure injury risk in immobile patients, and the need for co…
39y · Male·multiple injuries from motor vehicle collision
…idelines. The psychiatrist (Dr A.) had appropriately declined the commercial licence weeks earlier due to concerns about stability and community safety. Although this certification error did not directly cause the death …
56y · Male·acute pentobarbitone toxicity
…e, combined with toxic levels of zopiclone, less than two weeks after premature discharge from involuntary mental health care. After two suicide attempts in July and August 2016, the psychiatric team made critical defici…
44y · Male·Multiple injuries sustained in a motorcycle incident
…contributing factors. The coroner emphasised the need for mandatory medical reporting of fitness-to-drive concerns to VicRoads, as the current voluntary self-reporting system failed to identify the older driver's cogniti…
14y · Female·electrocution
Heidi Singh was a 14-year-old Aboriginal girl who died by electrocution at a railway pylon on 21 August 2014. She had suffered from foetal alcohol spectrum disorder since early childhood, experienced multiple losses (par…
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
…cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 …
37y · Female·Contact gunshot wound to the head
…g and threatening behaviour in the USA, where a protective order had been obtained and he was detained for mental health assessment. Upon returning to Tasmania, she consulted solicitors about obtaining protective orders …
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