654 results for “mental health issues”
41y · Male·Dilated cardiomyopathy
Raleigh Hoy, a 41-year-old man with schizophrenia and autistic spectrum disorder, died of dilated cardiomyopathy at a residential care facility (Tarampa After Care Centre) in Queensland in January 2007. While his mother …
45y · Male·spontaneous lethal arrhythmia arising from focal myocardial fibrosis
…and inadequate night-time observation protocols, represented shortcomings in care. The coroner found Mercy Health made reasonable subsequent improvements to observation forms and procedures.
48y · Female·Hypoxic/Ischaemic Encephalopathy; Aspiration of Food with Respiratory Arrest wit…
Kathryn O'Rourke, aged 48, a resident with severe intellectual disability and dysphagia in a disability residential care facility, aspirated a piece of toast during breakfast on 10 May 2018 and died from hypoxic-ischaemi…
Female, male·Stab wounds inflicted by Joel Cauchi
Joel Cauchi, suffering a psychotic relapse of chronic schizophrenia, carried out a rapid active armed offender (AAO) attack at Westfield Bondi Junction shopping center on 13 April 2024. Within three minutes, he fatally s…
16y · Female·Multisystem organ failure and cerebral hypoxia secondary to hanging
…failure and cerebral hypoxia. The coroner found no clinical medical error, but identified broader systemic issues relevant to youth suicide prevention. Taylor had searched online for hanging information and demonstrated …
12y · Male·Suicide by hanging
A 12-year-old Aboriginal boy living in a remote Queensland community died by suicide by hanging following his placement in alternative care by child protection services. The boy had multiple vulnerabilities including fet…
45y · Male·gunshot wound to the chest with associated significant blood loss
Stanley Russell, a 45-year-old Aboriginal man with mild intellectual disability, was shot dead by NSW police executing a bench warrant at his home on 9 November 2021. He had suffered childhood sexual abuse, his brother d…
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…
29y · Male·severe burns sustained in motor vehicle fire following collision
…Vehicle Registry failed to inform Dr G. of the crash history. The coroner concluded the system failed fundamentally and that a Review Panel for complex fitness-to-drive cases, with access to all medical and police inform…
49y · Male·complications of non-small cell carcinoma of the lung
…ionships, failed to obtain specialist information about cancer prognosis, did not complete a comprehensive health assessment plan, and did not recognise palliative care needs despite Howlett receiving such care in the co…
82y · Male·Complications associated with advanced chronic lung disease
…existed between the hospital and Department of Corrective Services regarding notification of deteriorating health status and implementation of palliative care plans.
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
…uate clinical oversight of a junior doctor responsible for 1150 inmates. The coroner found the delivery of healthcare was 'chaotic' due to severe understaffing, with one GP managing a population that contractually requir…
22y · Male·Hypoxic Ischaemic Encephalopathy due to suffocation
…astic bag from his police lockup property. The coroner found the death was suicide and identified systemic issues: retention of plastic bags in prisoner property, delays in cell alarm response systems, and communication …
41y · Male·mixed drug toxicity (methadone, valproate, zuclopenthixol)
Michael David Rex, a 41-year-old man with chronic treatment-resistant paranoid schizophrenia, died from mixed drug toxicity (methadone, valproate, zuclopenthixol) while detained in Ward 5H of the Margaret Tobin Centre ps…
46y · Male·Aspiration pneumonia in an obese man with a history of diabetes mellitus, obstru…
Samuel Edward Ashby, a 46-year-old prisoner with treatment-resistant schizophrenia, died from aspiration pneumonia complicated by clozapine effect. Key clinical lessons: (1) smoking cessation dramatically increases cloza…
74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while …
41y · Male·Stab wound to the chest
…s compliance with community orders and psychological treatment; and lack of domestic violence screening in health services. Men's behaviour change programs were unavailable due to Jack's transience. The coroner identifie…
31y · Male·undetermined
…s were used. Forensicare subsequently implemented significant improvements including standardised physical health monitoring systems, mandatory use of observation charts during seclusion, clearer escalation pathways, and…
38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia
A 38-year-old remand prisoner with schizophrenia on clozapine died suddenly in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to prison on 20 Jul…
1y · Female·complications of acute bronchiolitis arising from Respiratory Syncytial Virus (R…
A 17-month-old First Nations child died from acute bronchiolitis due to respiratory syncytial virus (RSV) infection in inadequate accommodation following parental separation from domestic violence services. The coroner i…
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