654 results for “mental health issues”
56y · Female·pulmonary thromboembolism due to left calf deep vein thrombosis
…isorder died from pulmonary thromboembolism due to left calf deep vein thrombosis while detained under the Mental Health Act in hospital. She presented with seizures and underwent wrist surgery. On 13 July, an intern not…
32y · Female·Effects of fire
A 32-year-old woman died in a house fire at her rented home on 22 March 2024. Fire Rescue Victoria classified this as a preventable fatality. The deceased was overcome by smoke while sheltering in the bathroom after the …
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…
41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity
…specialist pain medicine review (best practice every 18 months) and potential Schedule 8 permit compliance issues. No evidence of suicidal intent. Death likely accidental overdose. Case illustrates systemic challenges in…
36y · Male·Ligature strangulation
…ing judge, he consistently refused engagement. Bloomfield could not be compelled to accept treatment under mental health legislation as he did not meet criteria for involuntary treatment—he had capacity to refuse and did…
33y · Male·Extensive burns sustained when former partner deliberately splashed petrol on hi…
…and systems abuse; explicit assessment of risk to receiving parent when children transition care; need for mental health specialist involvement in safety planning; importance of multi-agency information sharing to preven…
39y · Male·Excited delirium, probably caused by amphetamine toxicity-induced psychosis. Dea…
Antonio Carmelo Galeano died in police custody on 12 June 2009 after a protracted struggle and multiple taser activations. He had acute amphetamine toxicity and was displaying excited delirium—a high-risk medical emergen…
Female·Five separate deaths: Ruby Nicholls-Diver—ligature compression of neck (hanging)…
…hin 24 hours of discharge), these deaths may have been preventable or their likelihood decreased. Systemic issues included inadequate policies supporting carer engagement, time pressures on clinicians, and lack of integr…
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…
Male·Pulmonary thromboembolism and bronchopneumonia secondary to deep vein thrombosis
…and bronchopneumonia. He received palliative care at home provided by his partner PJN, who had undisclosed mental health issues and a history of violence. Multiple healthcare workers documented concerns about PJN's capac…
45y · Female·mixed drug toxicity including heroin and methylamphetamine
Barbara Dobson, a 45-year-old woman with a long history of substance abuse, violent relationships, and mental health issues, died of mixed drug toxicity including heroin and methylamphetamine on 24 February 2020. Pol…
58y · Male·multiorgan failure due to sepsis resulting from repeatedly fractured left humeru…
…ave been prevented given his poor baseline state, the fall hastened his decline. The coroner commended the health service for implementing improved falls risk screening tools and prevention strategies hospital-wide.
87y · Male·Complications of head injuries in setting of dementia
…ent Team referral was being arranged but not completed before the assault. The coroner identified systemic issues: under-reporting of resident-to-resident aggression due to legislative exemptions when perpetrators have c…
35y · Male·Not determined
Benjamin Batalha, aged 35, died in custody at Arthur Gorrie Correctional Centre. The exact cause of death could not be determined, though respiratory depression from mixed drug toxicity or fatal arrhythmia were likely. H…
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…
16y · Male·Gunshot wound to the head
A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 August 2001. He had been under psychiatric care for 10 months, p…
Female·Multiple causes: Ruby Natasha Nicholls-Diver: ligature compression of neck (hang…
… months (March 2011-March 2012). Two died within 24 hours of discharge, demonstrating critical failures in mental health service delivery. Key clinical lessons: (1) Individual management and risk assessment plans must be…
Male·Self-inflicted hanging
Leon Mark Carroll died by hanging in prison while on remand for sexual offences. Initial assessment identified significant suicide risk, but this was reversed by the High Risk Assessment Team after only 5-6 minutes consi…
48y · Male·combined drug intoxication from morphine and quetiapine
Brett Cashion, a 48-year-old man with chronic pain and mental health issues, died from combined morphine and quetiapine intoxication after injecting prescription morphi…
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…
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