Coronial

113 results for behavioural disturbance

SAhospital2011-10-06

Coroner's Finding: BROWN Kunmanara

18y · Male·Hypoxic brain injury following cardiac arrest due to neck compression from hangi…

… incident. Clinical lessons include: (1) recognition that volatile substance inhalation can cause acute behavioural disturbance presenting as psychiatric emergency; (2) the Mental Health Act 2009 provisions allowing ass…

emergency medicineintensive carecommunicationsystempetrol
WAmental health2001-02-02

Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

…ac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed severe behavioural disturbance resistant to anti-psychotic medication, progressing to medication-induced delirium. He was …

psychiatryintensive caremedicationflupenthixol decanoate
WAmental health2013

Inquest into the Death of Vos, Glenis June

60y · Female·Focal pneumonia in a woman with emphysema and ischaemic heart disease

…ng ICU-level care. On the evening before death, she was sedated with temazepam (20mg) for agitation and behavioural disturbance in a secure ward. She was found unresponsive the following morning, having apparently died …

psychiatrygeneral medicinetemazepam
SAhospital2021-06-30

Coroner's Finding: VOIVODICH Guido

84y · Male·general inanition on a background of end-stage dementia and a fractured neck of …

84-year-old man with end-stage dementia died from general inanition following a fractured neck of femur sustained while under a Level 2 Inpatient Treatment Order. He was admitted in January 2019 with confusion and agitat…

psychiatrygeriatric medicineapixaban
SAhospital2021-11-23

Coroner's Finding: Beahl, Raymond Saxon

81y · Male·metastatic rectal adenocarcinoma with infected necrotic sacral ulcer

…acral ulcer. He was admitted to Oakden Older Persons Mental Health Service with severe dementia-related behavioural disturbance (Tier 7 BPSD) and terminal cancer. Critical failures included: inappropriate prolonged phys…

psychiatrypalliative carediagnosticcommunicationamoxicillin/clavulanate
NSWmental health2019-02-12

Inquest into the death of Kevin O’Halloran

55y · Male·positional asphyxia, with sedation as an underlying risk factor

Kevin O'Halloran, a 55-year-old with chronic schizophrenia, presented with acute severe behavioural disturbance related to medication changes and possible substance use. He received substantial intraveno…

emergency medicinepsychiatrycommunicationproceduralmidazolam
SAhospital2009-08-12

Coroner's Finding: HOPE Maria Kate

55y · Female·hypoxic brain injury complicated by aspiration pneumonia

…g herself with a plastic bin liner while hospitalised in a rural hospital. She was admitted following a disturbance where she threw stones at a neighbour's house. Although nursing staff observed her with a small plastic…

general practicepsychiatrycommunicationdiagnosticolanzapine
NSWcommunity2020-07-17

Inquest into the disappearance and suspected death of Max DAY

53y · Male·unknown - no postmortem examination possible

… death due to absence of remains. The case highlights challenges in managing persons experiencing acute behavioural change and mental health crises, particularly when resources are limited and individuals disengage from…

psychiatryemergency medicine
SAhospital2019-10-29

Coroner's Finding: PEMBERTON Graham Ashton

87y · Male·aspiration pneumonia, urinary tract infection and general inanition complicating…

…urinary tract infection, and general inanition. He was admitted to hospital multiple times in 2015 with behavioural disturbance, agitation, and medical complications including urinary retention and pneumonia. He require…

geriatric medicinepsychiatry
VICcommunity2009-10-23

Finding into death of Gregory Ram Biggs

27y · Male·external blood loss due to laceration of right axillary artery from single gunsh…

… preventable. Critical clinical and systemic lessons include the importance of recognizing drug-induced behavioural changes—Biggs had recently increased amphetamine use and tested positive for MDMA, methamphetamine, amp…

emergency medicineforensic medicinecommunicationsystemMDMA
SAhospital2001-05-16

Coroner's Finding: HAMPTON Ronald Allen

77y · Male·respiratory failure caused by severe pneumonia

…re pneumonia while detained under the Mental Health Act at Glenside Hospital. He had been admitted with behavioural disturbances related to dementia. When pneumonia developed, he was transferred to the Royal Adelaide Ho…

psychiatrygeneral medicineantibiotics
SAhospital2012-09-19

Coroner's Finding: STEAD Kenneth Alfred

79y · Male·delirium due to aspiration pneumonia complicating advanced metastatic non-small …

A 79-year-old man with metastatic lung cancer suffered multiple strokes causing confusion and behavioural disturbance. He was detained under Mental Health Act. On the night shift, nursing staff found him unres…

oncologygeriatric medicinecommunicationsystem
VICmental health2015-06-16

Finding into death of John Wilfred Knight

71y · Male·Sepsis due to bronchopneumonia and sacral ulcer

…chiatric inpatient unit after five months admission for frontotemporal dementia management. His complex behavioural and cognitive decline required multiple psychotropic medication trials including antipsychotics, benzod…

psychiatrygeriatric medicineolanzapine
WAhospital2015-02-26

Inquest into the Death of Peta Susan DOIG

58y · Female·pneumonia and cardiac failure complicated by hypoxic brain injury

…sed at Graylands Hospital since age 13-14 due to lack of appropriate community accommodation and severe behavioural difficulties. On 3 January 2013, she developed a chest infection with low oxygen saturation (93%). Desp…

psychiatryintensive carediagnosticdelayazithromycin
VIChospital2025-10-09

Finding into death of Graham Keith Moore

57y · Male·Pneumonia with contributing factors of trisomy 21 and early Alzheimer's dementia

…ded support. In early January 2025, he experienced multiple falls, agitation, hallucinations, and sleep disturbance, prompting hospital admission. During his one-month hospital stay, he developed urinary retention, poor…

general medicinegeriatric medicineintravenous fluids
SAhospital2020-12-18

Coroner's Finding: FROST Gary Desmond

57y · Male·Right acute subdural haematoma following a fall

…ome was difficult to prevent. No systemic failures or negligence were identified. The patient's complex behavioural needs and intellectual disability made management challenging but appropriate clinical decisions were m…

emergency medicineneurosurgery
NSWhospital2017-07-07

Inquest into the death of Benjamin Gilligan

22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree

…e gate leave documentation with families; establish coordinated state-wide approach to acute behavioral disturbance in EDs; implement discharge planning before leave; ensure family understanding of clinical decisions.

psychiatryemergency medicinecommunicationsystemmethamphetamine
VICcommunity2024-07-29

Finding into death of Andrew David Berry

41y · Male·sympathomimetic syndrome

…g); consideration of direct hospital transport for severely drug-affected persons presenting with acute behavioural disturbance; and adequate monitoring during police transport. Dr W. opined earlier medical assessment m…

emergency medicineforensic medicinesystemdelaymethamphetamine
QLDhome2008-09-19

12 year old boy at Kowanyama

12y · Male·Suicide by hanging

…e boy had multiple vulnerabilities including fetal alcohol syndrome, intellectual disability, emotional disturbance, and prior behavioural concerns. Child safety officers, one of whom was untrained and inexperienced, in…

paediatricspsychiatrydiagnosticsystem
VIChospital2021-02-26

Finding into death of MrJ

22y · Male·Drowning

A 22-year-old university student with recent substance use presented to ED following violent behaviour. He had facial trauma with mild head injury and abnormal metabolic parameters. Initial management appropriately prior…

emergency medicinepsychiatrysystemdelayMDMA

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