79 results for “psychiatric disturbance”
26y · Male·Not able to be determined - skeletalised remains
… use and a period of erratic behaviour. He was briefly assessed by nursing staff but discharged without psychiatric review. Community mental health follow-up was arranged but failed due to inability to contact him (no p…
28y · Male·Traumatic brain damage complicating contact .22 calibre gunshot wound to the mid…
…individual who had no prior mental health contact and made no meaningful communication possible. Expert psychiatric evidence concluded that even with hindsight, the serious mental state and tragic outcome could not have…
47y · Female·Ligature compression of the neck (suicide by hanging)
Tracy Margaret Marshall, a 47-year-old woman admitted to Nickol Bay Hospital as a voluntary patient due to deteriorating mental state and suicidal ideation, left the hospital on 21 February 2011. She drove to a remote lo…
71y · Male·Sepsis due to bronchopneumonia and sacral ulcer
Mr John Knight, aged 71, died from sepsis secondary to bronchopneumonia in a psychiatric inpatient unit after five months admission for frontotemporal dementia management. His complex behaviou…
40y · Male·Unascertained; likely cardiac arrhythmia secondary to cardiomegaly and morbid ob…
Peter John William Fallon, aged 40, died in the psychiatric intensive care unit at Queen Elizabeth Hospital on 2 February 2013 of unascertained cause. He had bipol…
36y · Male·Unknown; presumed unsurvivable injuries or drowning following intentional cliff …
…as otherwise well with no suicidal ideation at his last review on 21 June 2019, though they noted sleep disturbance. The coroner found the decision to cease clozapine reasonable but noted the reduction rate could have b…
31y · Male·Combined Drug Toxicity (amitriptyline and metoclopramide)
…ssments in 2017-2018 identified depression, anxiety, and despair but he did not engage with recommended psychiatric treatment or counselling. He had cancelled a scheduled psychological consultation on the day of his dea…
19y · Male·Ruptured aorta post motor vehicle incident
…l family involvement in discharge planning despite family concerns; and no diagnosis despite persistent disturbance of thought/mood. Clinicians prioritised maintaining therapeutic alliance over rigorous risk assessment.…
35y · Female·Stab wounds to the chest
…ober and November 2019, diagnosing depression and prescribing Valdoxan, but did not assess or refer for psychiatric evaluation despite clear evidence of psychotic symptoms and prior history of schizophrenia. Police atte…
50y · Male·Hanging
A 50-year-old man with Parkinson's disease died by hanging in a psychiatric inpatient unit while on a Temporary Treatment Order. His mental and behavioural symptoms were secondary…
27y · Male·multiple injuries after a fall from a height
…er a 7-day detention order. He had been admitted following an assault charge and was experiencing acute psychiatric symptoms. He was found dead on 11 October 2004 at the base of a power pole with fatal injuries from a f…
54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus
… he developed profound sedation and neurological deterioration. Critical issues included: lack of daily psychiatric review in the Special Care Unit (he was not seen on day 3 post-sedation); delayed recognition of seriou…
65y · Male·hypoxic ischaemic encephalopathy complicating hanging
…he next morning, diagnosing steroid withdrawal instead. The medical team then planned discharge without psychiatric review. Critical failures included: misdiagnosis of the underlying steroid-induced syndrome, failure to…
51y · Female·Complications of anorexia nervosa
…sessment despite evidence of cognitive impairment from starvation; no communication between medical and psychiatric teams about discharge planning; discharge despite her refusal to eat and presence of life-threatening c…
50y · Male·hepatic encephalopathy secondary to liver cirrhosis with background of hepatitis…
…course was complicated by non-compliance, alcohol use during brief absconding episodes, and behavioural disturbance requiring psychiatric detention and restraint. The coroner found his detention lawful and medical treat…
29y · Male·Penetrating wound to neck with vascular injury to the carotid sheath
Louis Bernard Taylor, a 29-year-old Aboriginal male, died from a penetrating wound to the neck inflicted by himself on 23 August 2002. Recently released from prison after four years incarceration, Louis was attempting to…
21y · Male·Compression of the neck consequent upon hanging
…e behaviour; inadequate communication between emergency and mental health teams; and insufficient acute psychiatric beds leading to prolonged ED stay. The coroner recommended implementing a dedicated behavioural assessm…
29y · Male·Unascertained
…clude: uncertainty persists despite toxicology; complex polypharmacy in disability care requires expert psychiatric input; regular contact with neurology and psychiatry is important despite seizure stability; and contem…
57y · Male·Neck compression and hanging
…s, his engagement with mental health services remained poor with persistent lack of insight. He refused psychiatric appointments in June-July 2024 but showed no overt suicidal ideation or self-harm. The coroner found no…
46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)
…ncreases suicide risk, particularly when multiple stressors accumulate; the importance of continuity of psychiatric care during employment transfers; and recognition that formal disciplinary processes (even for minor is…
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