621 results for “mental health concerns”
43y · Female·unknown
…ers regarding restraint; police communications protocols for hospital discharges should ask about welfare concerns; and interdisciplinary communication gaps delayed reporting her as missing.
22y · Male·Hanging
…ent, no family involvement in monitoring despite available options, inadequate follow-up on a pre-existing mental health condition, and insufficient product labelling accessible to patients.
23y · Male·Hypoxic-ischaemic encephalopathy due to hanging
…n 8 February 2016 (declared extinct 12 February 2016). He had a history of substance abuse, self-harm, and mental health difficulties. The key clinical lesson concerns information sharing between Offender Health Services…
Unknown·Ruby: ligature compression of neck (hanging); Carly: ligature compression of nec…
…ng adults died by suicide within 12 months (March 2011 to March 2012), all connected to Alma Street Centre mental health services at Fremantle Hospital. Four were discharged (Ruby Nicholls-Diver, Carly Elliott, Michael T…
34y · Male·mixed drug overdose (heroin, methadone, codeine, diazepam, nitrazepam, oxazepam …
…discharge of overdose patients with polysubstance use and social chaos; (2) inadequate risk assessment and mental health screening despite substance use disorder; (3) lack of coordination between multiple prescribers all…
18y · Female·Hypoxic brain injury secondary to hanging
…d a prior hanging attempt using the same hooks. Key lessons include the importance of comprehensive environmental safety assessment, documented risk escalation procedures, and interdisciplinary communication between inpa…
15y · Female·neck compression due to hanging
…lise available psychiatric expertise, and inappropriately withheld father's involvement despite his known concerns. Earlier psychiatric assessment and comprehensive risk management could have altered outcomes.
32y · Female·combined drug toxicity, mainly heroin
Natasha Calleja, 32 years old, died from combined drug toxicity (mainly heroin) while an involuntary inpatient at Swanston Centre psychiatric unit after her de facto partner supplied heroin during an unsupervised visit. …
34y · Male·Neck compression by hanging
…nsufficient consideration of contextual stressors, and systemic failures in maintaining appropriate environmental safeguards. The death was preventable through proper closure of identified hanging points and continuous s…
31y · Male·Overdose of quetiapine (Seroquel) in combination with alcohol
Travis Graham, a 31-year-old man with a history of mental illness, self-harm, and substance abuse, died from an overdose of quetiapine (Seroquel) combined with alco…
26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)
A 26-year-old man with schizophrenia, antisocial personality disorder, and polysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff…
0y · Unknown·Category II Sudden Infant Death Syndrome (co-sleeping)
Baby J, a healthy 23-week-old infant, died from Category II Sudden Infant Death Syndrome (SIDS) associated with co-sleeping…
15y · Male·Hypoxic ischaemic brain injury, due to hanging
…igns of depression or self-harm risk to family, school staff, or his doctor. The critical clinical lesson concerns the delayed communication of school absences to parents—the school failed to contact his family until 10 …
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
29y · Female·multi-lobe community acquired pneumonia and respiratory failure
…ng despite her severe malnutrition due to her profound opposition, recognised risks of physical harm, and concerns about therapeutic rapport. On 26 January, active treatment was withdrawn as futile. The coroner found the…
41y · Female·mixed drug and alcohol toxicity
Karen Louise Richards, 41 years old, died from mixed drug and alcohol toxicity on 11 January 2014. She had consumed heroin (evidenced by 6-MAM metabolite), alcohol, benzodiazepines, and other prescription medications. He…
12y · Male·Suicide by hanging
…s including fetal alcohol syndrome, intellectual disability, emotional disturbance, and prior behavioural concerns. Child safety officers, one of whom was untrained and inexperienced, investigated a notification of suspe…
51y · Male·Incised wound to the right arm
…al negligence contributed directly to the death, procedural and documentation failures in the correctional health system were identified.
33y · Male·methylamphetamine toxicity; antecedent causes being the physiological effects of…
A 33-year-old man with methamphetamine addiction and possible schizophrenia attended the ED seeking help while acutely intoxicated, psychotic and sleep-deprived. After initially agreeing to medication, he attempted to le…
Multiple - hanging (2), unknown/unascertainable (1), multiple injuries from fall…
…ssment; inadequate procedures for addressing longitudinal risk factors; poor integration between different mental health services; insufficient follow-up after discharge, particularly in the first 24-48 hours; and inadeq…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.