264 results for “conduct disorder”
33y · Female·multiple injuries sustained when struck by a train
Naomi Mahon, a 33-year-old woman with bipolar affective disorder and substance use issues, died after being struck by a train shortly after absconding from Monash Medical…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
… in ED (62 hours) due to bed block, with seclusion occurring without proper documentation; (2) failure to conduct required respiratory checks during night observations despite policy requirements; (3) failure to impleme…
46y · Female·brain swelling and dural venous thrombosis in association with low grade glioma …
…iting, and visual disturbances. Dr G. diagnosed migraine based on her history and symptoms, but failed to conduct comprehensive neurological examination or assess for papilloedema despite multiple red flags. He did not …
42y · Male·ligature compression of the neck (hanging)
Wayne Larder, a 42-year-old man with depression, suicidal ideation, and substance use disorder, died by hanging in Hakea Prison on 22 February 2021. Critical failures in suicide risk management includ…
17y · Female·self-inflicted hanging
… four years of unstable placements (26 total) and fragmented mental health care. Despite evidence of mood disorder and suicide risk, she disengaged from psychological counselling in January 2014 and refused further treat…
21y · Male·complications of ligature compression of the neck (hanging)
Sarwan Al Jhelie, a 21-year-old Iraqi-born man in immigration detention, died by suicide on 5 September 2018 after hanging himself. He had a history of trauma, depression, drug abuse, and prior self-harm and overdose att…
14y · Female·electrocution
…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 (parents, carers), and was chronically at risk of self…
25y · Female·multiple injuries
…mpanied access to a rooftop café with a scalable glass balustrade. Key preventive opportunity: failure to conduct mental health handover and suicide risk assessment before allowing unaccompanied ward leave, and inadequa…
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for or…
41y · Male·Gunshot wounds to the head and torso
Duy Linh Ho, a 41-year-old man with long-standing substance use disorder and untreated mental health issues, died from gunshot wounds after a police response to his self-harm and…
53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging
Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…
smoke inhalation and burns from deliberately-lit fire (primary cause varies by i…
…to recognise signs of drug dependency in colleagues, inadequate protocols for managing suspected staff misconduct, and lack of supervision for night-shift nursing. Recommendations include mandatory employment notificati…
48y · Male·Gunshot wound to the chest during a police operation
…oking police to shoot him. He had a complex mental health presentation comprising depression, alcohol use disorder (consuming approximately a carton of beer daily by January 2023), and chronic back pain. After presenting…
43y · Male·Undetermined — available evidence does not allow determination due to limitation…
…d not be definitively established but included possible smoke inhalation, seizure from alcohol withdrawal disorder, traumatic head injury from alleged third-party assault, or natural causes. Since 2000, substantial impro…
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
…Maroondah Hospital and assessed by psychiatric nurse Gary Cox about 4 hours after arrival. Mr Cox did not conduct a formal mental state examination or risk assessment despite knowing of her recent attempted hanging, foc…
32y · Female·hanging
…alth assessment findings were not properly followed up. WAYSS (housing/family violence service) failed to conduct proper risk assessment when Ms Burke presented for housing support despite prior family violence contact …
52y · Male·Hanging
…rectional Centre. He was not considered a suicide risk based on psychiatric assessment showing adjustment disorder with no psychotic features or suicidal ideation. McBride was housed in older-style cells containing acces…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
32y · Female·Compression of the neck
FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…
29y · Male·Hanging
…self-harm behaviour during family violence incidents. Critical failures included: Victoria Police did not conduct adequate risk assessment before serving the FVIO despite Person Warning Flags on his record indicating su…
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