2,612 results
22y · Female·Unascertained
Beilin Zhang, a 22-year-old international student, disappeared on or about 20 August 2018 from Sydney. She was found to be deceased, though her body was never located. Clinical lessons include recognition of depression s…
59y · Male·Hanging
Paul Hannan, a 59-year-old man with significant alcohol dependence and prior mental health issues including depression, died by hanging in custody at Metropolitan Remand Centre in September 2020. He was referred for cust…
27y · Male·Mixed drug (methylamphetamine and clozapine) toxicity
KT, a 27-year-old with treatment-resistant schizophrenia, died in custody from mixed drug toxicity (clozapine and methylamphetamine). He was prescribed appropriate clozapine treatment with adequate monitoring. Key failur…
84y · Male·Respiratory failure complicating hospital acquired pneumonia following surgical …
An 84-year-old man died from respiratory failure due to hospital-acquired pneumonia following surgery for recurrent mandibular squamous cell carcinoma. Key clinical lessons: (1) Advanced Care Plans (ACPs) must be activel…
32y · Male·Hanging
Mr W, a 32-year-old man with lifelong anxiety, previous suicide attempts, and childhood trauma, died by hanging on 5 April 2019. He had been receiving care from a psychologist (Dr C.) and GP (Dr S.) since December 2018, …
35y · Female·aortic dissection with associated acute aortitis
A 35-year-old Aboriginal woman with schizoaffective disorder presenting with acute psychosis and chest pain was appropriately referred for psychiatric assessment and retrieval. CareFlight transport was timely and the rec…
46y · Male·atherosclerotic heart disease
Frank Albert, a 46-year-old Aboriginal man, died from atherosclerotic heart disease while incarcerated at West Kimberley Regional Prison. Although his death was caused by severe coronary artery disease unrelated to medic…
63y · Male·Hypoxic ischaemic brain injury and pneumonia complicating cardiac arrest in a ma…
Armin Schaefer, a 63-year-old man with schizophrenia, cardiac risk factors, and emphysema, died from hypoxic-ischaemic brain injury and pneumonia following cardiac arrest on a psychiatric unit. He presented to ED on 15 A…
23y · Female·Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of t…
Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination …
35y · Female·neck and chest injuries and drowning due to intentional fall/jump from Tasman Br…
Jana Culic, aged 35, died by suicide jumping from the Tasman Bridge on 4 June 2020 while subject to a Mental Health Act treatment order for schizophrenia, borderline personality disorder, and bipolar disorder. She had a …
27y · Male·hanging
A 27-year-old man with deteriorating mental health and acute psychotic symptoms died by hanging from a bathroom door in an acute mental health unit. He had expressed suicidal ideation, told his parents he needed to die t…
25y · Male·Dehydration with contributory causes of severe mental health conditions and hype…
Darren Higgins, a 25-year-old Wiradjuri man with treatment-resistant schizophrenia and polysubstance abuse disorder, died from dehydration and hyperthermia in Moira State Forest after absconding during escorted weekend l…
68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…
Irene Charlish, a 68-year-old woman with longstanding schizoaffective disorder and multiple comorbidities, fell at her residential facility on 6 June 2017, sustaining a pneumothorax and rib fracture. She was admitted to …
31y · Male·self-inflicted hanging
Bernard Hector, a 31-year-old Aboriginal man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearan…
39y · Male·Injuries sustained in a fall from the Camberwell train station bridge
Justin Crome, a 39-year-old man with delusional disorder and schizophrenia, died by suicide after jumping from a railway bridge on 13 February 2020. He had a history of mental illness since 2016, multiple psychiatric adm…
64y · Female·Combined toxicity to alcohol and baclofen
Anna Lawrence, 64, died from combined toxicity of alcohol and baclofen on 30 April 2020. She had a 40+ year history of alcohol dependency, borderline personality disorder, depression, and multiple suicide attempts. Baclo…
76y · Male·Streptococcus pneumoniae sepsis in the setting of acute bronchopneumonia and ren…
Terence Michael Brooks, a 76-year-old man with dementia, vascular disease, and depression, died of streptococcal pneumoniae sepsis with acute bronchopneumonia and renal failure from obstructive uropathy at an aged care f…
58y · Male·coronary artery arteriosclerosis (natural causes)
Philip Sulley, 58, died of coronary artery arteriosclerosis on 27 April 2020 at Bentley Mental Health Unit. He presented to Royal Perth Hospital emergency department on 19 April 2020 with psychotic behaviour but was disc…
18y · Male·asphyxia by hanging; intentional self-harm
Joshua, 18, died by suicide at an ANU residential hall in August 2018, several weeks after a serious self-harm incident requiring hospitalisation. Key clinical lessons emerge: (1) Inadequate coordination between ACT Ment…
44y · Male·Unascertained; presumed exposure
Roly Nixon, a 44-year-old man with significant medical comorbidities including rheumatic heart disease, diabetes, organic psychosis and seizure disorder, disappeared from Fitzroy Crossing, Western Australia on 28 January…
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