391 results for “psychiatric medication management”
41y · Male·Hanging
… died by hanging in Port Phillip Prison in March 2008. The coroner identified multiple system failures: psychiatric assessment referrals were not acted upon despite evidence of deteriorating mental state and suicidal id…
54y · Male·hanging
… did after his accident. Clinical lessons: The coroner found no documented counselling or warning about psychiatric adverse effects when he reported self-recommencement, and no clinical review occurred. Current prescrib…
67y · Male·Hypertensive cardiomegaly and ischaemic heart disease
…was arrested after making threats at Federal Police offices. He was admitted involuntarily to John Cade Psychiatric Unit under the Mental Health Act 1986. On admission, psychiatry certified him as involuntary and admini…
60y · Male·Ischaemic heart disease
… while an inpatient in a mental health facility under an Inpatient Treatment Order. He was admitted for psychiatric management after non-compliance with clozapine. He was found unresponsive in a bathroom and resuscitati…
31y · Male·Combined effects of multiple drugs in an obese male with findings suggestive of …
Simon Mark Gray, a 31-year-old man, died from combined effects of multiple medications in the setting of obesity and bronchopneumonia, less than 24 hours after discharge from psychiatric hos…
26y · Female·Hypoxic brain injury in the setting of immersion
Amy Hauserman, a 26-year-old woman with schizophrenia and anorexia, was admitted to a psychiatric ward with acute psychosis due to non-compliance with clozapine. Over two days, she developed severe abd…
46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…
Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric inte…
48y · Male·Unknown causes (presumed suicide by drowning)
…closed suicidal preoccupation for ten days—he was not admitted to hospital or given immediate intensive psychiatric care. Dr R. believed the danger had passed after their consultation, but Mr Morgan's condition deterior…
32y · Male·Valproic Acid Overdose
…rder, died from valproic acid overdose at a crisis accommodation facility. He was admitted to John Cade Psychiatric Unit following a benzodiazepine overdose on 13 March 2008. Despite a clear history of impulsive self-ha…
45y · Male·focal coronary artery disease and cardiomegaly
…dah Hospital on 28 March 2025 from focal coronary artery disease and cardiomegaly during an involuntary psychiatric admission. He presented with acute psychosis from bipolar disorder requiring emergency response and Men…
81y · Male·myocardial infarction
…at Glenside Hospital. He was admitted for aggression and cognitive deterioration. Over three weeks, his psychiatric medication (olanzapine, carbamazepine) was adjusted as he appeared to improve. He collapsed suddenly on…
42y · Male·Ligature compression of the neck (hanging)
…in treatment silos without multidisciplinary meetings or effective information sharing. Dr F., a senior psychiatric registrar (not consultant psychiatrist) covering for an absent senior clinician, ceased olanzapine medi…
63y · Male·Incised injuries to the neck and upper limbs
…depression in April-May 2022 and received electroconvulsive therapy. Post-discharge, he disengaged from psychiatric care in July 2022, ceased prescribed medications, and self-prescribed cannabis oil. His community menta…
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
…s present with altered consciousness or unusual sedation, particularly before administering psychotropic medications; (2) staff managing residents with both mental health conditions and substance use disorders require ap…
46y · Male·Coronary artery atherosclerosis
…e monitored and managed appropriately after respiratory depression emerged, he spent ~14 hours awaiting psychiatric admission with delayed registrar assessment. He died from coronary artery atherosclerosis (underlying c…
39y · Male·combined drug toxicity
…ostic justification or appropriate monitoring. Critical clinical lessons: after hospital discharge from psychiatric admission in June 2012 with documented recommendation to reduce oxycontin to 20mg daily due to medicati…
52y · Male·Multiple injuries and immersion leading to hypoxic brain injury and pneumonia
… Casey Mental Health Service from 30 December 2008 to 16 January 2009. The coroner examined Y's clinical management and discharge planning. Key issues identified: inadequate forensic psychiatric assessment of Y's risk to…
24y · Female·Mixed drug toxicity
Sheridan Burnell, 24, died from mixed drug toxicity following an intentional overdose of prescription medications (lamotrigine and quetiapine) on 2 January 2021. Her mental health care was reasonable and appropriate. …
43y · Female·neck compression due to hanging
…d previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant medication for years due to fixed beliefs about '…
45y · Male·exsanguination due to incised wound to neck
…ical lessons include: (1) reception staff failed to adequately explore Mr McCarty's disclosure of prior psychiatric care; his medical records documenting depression, anxiety, previous suicide attempt, and suicidal ideat…
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