654 results for “mental health issues”
41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …
…of recognising hypovolemic shock presenting as dizziness, failure to escalate in vulnerable patients under mental health orders, and need for clear emergency protocols in supported accommodation settings.
29y · Male·Stab wound to the chest
…im accountable, though the coroner acknowledged Joshua's death may not have been preventable. Key systemic issues included poor documentation, inadequate compliance monitoring, and delays in authorising contravention act…
0y · Male·unascertained; possibly asphyxiation related to sleeping position
…would likely have followed, potentially altering Noah's care and home environment assessment. Contributing issues included inadequate communication of clinical information to radiology, incomplete radiological examinatio…
41y · Male·Hanging
…le system failures: psychiatric assessment referrals were not acted upon despite evidence of deteriorating mental state and suicidal ideation; the downgrade of his suicide watch rating on 20 March was based on a non-clin…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
…edical assessment. However, RPH nursing staff failed to read the transfer documentation, did not conduct a mental health risk assessment on admission, and progressively allowed unsupervised leave despite previous abscond…
27y · Female·multiple gunshot injuries with a stab injury to the heart
…w acceptable standards and that it negated any chance of rapid police intervention. Penny had a history of mental health issues and substance use. The case highlights critical failures in emergency call-taking protocols,…
50y · Male·Neck compression secondary to hanging
…e services that, while not causally linked to his death, warrant educational attention for clinicians. Key issues included: (1) Orange Door perpetrator support services failing to contact Jason following multiple police …
54y · Male·Cardiac arrest in a person with cardiac hypertrophy and generalised atherosclero…
…nthony Caristo died from cardiac arrest on 31 October 2017 following police deployment of a taser during a mental health crisis. He had consumed a lethal dose of methamphetamine, was actively self-harming with knives, an…
46y · Female·Multiple severe trauma suffered in a motor vehicle accident
A 46-year-old woman died in a head-on motor vehicle collision after her car drifted across the centre line on the Bass Highway. She had reported feeling tired earlier that morning and had intended to pull over to sleep. …
54y · Male·respiratory failure and acute renal failure due to rhabdomyolysis following trau…
A 54-year-old man with chronic schizophrenia and intellectual disability died from respiratory failure and acute renal failure secondary to rhabdomyolysis following a crush injury to his left thigh sustained while attemp…
16y · Female·Mixed drug toxicity
Maria Liordos, a 16-year-old in state care with complex trauma, substance abuse, mental health issues and high-risk behaviours, died from mixed drug toxicity. The coroner identified significant …
80y · Male·Drowning
An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…
48y · Female·head injuries from multiple blunt force trauma including punching, elbowing and …
…athy Tranter, was killed by her 20-year-old son who was an involuntary psychiatric patient at Orygen Youth Health (OYH) with acute paranoid schizophrenia. The son was granted overnight leave on 3 March 2009 despite sever…
Male·Hunt: self-inflicted gunshot wound to head; Reynolds: self-inflicted gunshot wou…
This coronial finding examined four police suicides in Tasmania between 2016-2020. Constable Hunt died by gunshot wound after being stood down from duty without welfare support; his personal phone was unlawfully seized, …
4y · Male·Oxycodone toxicity from ingestion of 80mg OxyContin tablet
… when families avoid contact; medical practitioners should refer dependent patients to specialist pain and mental health services; auditing of high-volume schedule 8 drug prescribers; and better inter-agency communicatio…
44y · Male·Multiple injuries sustained in a motorcycle incident
A 44-year-old man with complex psychiatric history and substance abuse was killed in a motorcycle collision while driving unlicensed and under the influence of methylamphetamine. A 92-year-old driver, disoriented after b…
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
…cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 …
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
…ic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at Silverwater MRRC: inappropriate cell placement on the top floor despite …
17y · Female·ligature compression of the neck (hanging)
…ed by suicide on 16 April 2017 after being discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver disease. Critical gaps were identi…
18y · Male·methadone toxicity
…ugh, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner found he likely…
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