654 results for “mental health issues”
41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…
…Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed by police. The inquest examined Cauchi's mental health management in Queensland before the attack. Key clinical failures identified: (1) gradual cessation…
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…
… life-threatening emergency could have provided intervention opportunity before he became symptomatic. Key issues included: limited CCTV monitoring of non-RIT inmates; lack of clinical detail on observation requirements …
21y · Male·complications of ligature compression of the neck (hanging)
…prior self-harm and overdose attempts. Key clinical lessons include: the failure to maintain continuity of mental health care after his transfer to Yongah Hill detention centre away from family and established supports; …
32y · Female·Neck compression in the setting of self-suspension
… reported ongoing physical, sexual and psychological abuse to police on 12 May 2020 and was assessed under mental health legislation, disclosing suicidal ideation. A Family Violence Intervention Order was made on 14 May …
41y · Female·Combined Drug Toxicity (ethanol and benzodiazepine)
…ned drug toxicity (ethanol and benzodiazepines) following an inadequate emergency services response to her mental health crisis. She called 000 expressing suicidal intent and reported consuming excess medication. Police …
28y · Male·neck compression subsequent upon hanging
…hotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute Unit at Ballarat Health Services following deteriorating mental health and was placed on 30-minute observations as a new admission…
20y · Female·Asphyxia secondary to inhalation of helium
Lauren Pilkington, a 20-year-old postgraduate student, died by asphyxia from helium inhalation. She had a history of anxiety and previous suicide attempt, and was recently discharged from voluntary psychiatric admission …
27y · Male·Cyanide toxicity
Phillip Reidy, 27, died from cyanide toxicity after ingesting sodium cyanide during police arrest for a family violence incident. He had purchased 250g of sodium cyanide online from Bacto Laboratories using false informa…
81y · Female·aspiration pneumonia, exacerbation of chronic obstructive airways disease (emphy…
Patricia Nina George, an 81-year-old woman detained under mental health legislation at Glenside Campus, died from aspiration pneumonia, COPD exacerbation and congestive he…
57y · Male·Hypoxic ischaemic encephalopathy secondary to prolonged downtime due to upper ai…
…nt system improvements including better document integration, mandatory updates to support plans following health changes, and new risk information sheets for participants.
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 physical assaults, co…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
…elf-inflicted stab wound to the chest. Key clinical and systemic lessons include: (1) Critical failures in mental health assessment—Corey's disclosure of hearing voices and anxiety (21 August 2024) and his urgent request…
29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath
…rsity. He was in emotional distress, struggling with systemic distrust, financial difficulties, and family issues. Two weeks before death, he consulted Dr S., who assessed him as not clinically depressed and provided a l…
42y · Male·hanging
…was ending. Although he had a 2001 history of depression and a prior suicide attempt documented in Justice Health records, this was not flagged in his February 2014 reception assessment. He denied suicide ideation on int…
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…
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…
49y · Female and male·Gunshot wound to head inflicted by spouse
… to protect Ms Lock despite her help-seeking, including: inadequate domestic violence screening by primary health care providers despite clear indicators; failure to refer Ms Lock to specialist domestic violence support …
35y · Male·Fentanyl toxicity
…eeking behaviour and Fentanyl dangers; poor medication security; inadequate coordination between agencies (mental health, community health, probation); failure to provide drug and alcohol rehabilitation despite clear ind…
17y · Female·Neck compression by hanging (suicide)
…e rather than relational practice, failure to facilitate family contact despite court orders, insufficient mental health supports (not culturally safe), inadequate support for carers, and repeated placement instability. …
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