654 results for “mental health issues”
56y · Male·Aspiration of gastric content secondary to combined drug toxicity
…nt secondary to combined drug toxicity. He had a long history of prescription drug dependency and multiple mental health issues. Two general practitioners prescribed long-term benzodiazepines (diazepam, temazepam) and qu…
34y · Male·Multiple injuries sustained in a fall from a height
…ner found police use of force was reasonable in the circumstances and did not contribute to his death. Key issues included lack of verbal warning before OC spray deployment, failure to maintain supervision of another det…
35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm
Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergenc…
80y · Male·Bronchopneumonia complicating terminal palliative care in an elderly man with ch…
…they had been informed earlier to better support his end-of-life care. The coroner found no preventability issues but noted the Department could have been more proactive in contacting family when his condition deteriorat…
38y · Female·Multiple injuries sustained in a motor vehicle accident in which the deceased wa…
…releasing intoxicated women at night without funds or accommodation planning. The case highlights systemic issues: inadequate 24-hour sobering shelter services, lack of safety protocols for vulnerable populations on rele…
14y · Female·Ligature compression of the neck (suicide)
…-depressant medications (fluoxetine then venlafaxine) prescribed off-label by her psychiatrist, Dr S.. Key issues identified: inadequate communication between public hospital (Princess Margaret Hospital) and private trea…
Boyd Lyle Scotty Farrer: Ligature compression of the neck (hanging); Esmay Alber…
Five Aboriginal people died in Oombulgurri, a remote East Kimberley community, between March 2005 and April 2006: four by suicide and one in a motor vehicle accident. Boyd Farrer (16), Alicia Rex (15), Paul Mitchell (21)…
54y · Male·Multiple injuries from collision with motor vehicle
…dman) who lacked required authorization. The supervisor cited Mr Gray's alleged intoxication and ticketing issues, despite NSW Trains policy prohibiting removal for ticketing alone. Police, unaware of their statutory pow…
70y · Female·Gunshot wounds to the head and chest
Marilyn June Burdon, aged 70, was fatally shot by her intimate partner Charles Bisucci on 21 August 2017 in Kew, Victoria. Bisucci subsequently took his own life. Critical systemic failures enabled this preventable intim…
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
83y · Female·Pneumonia complicating rib and pelvic fractures sustained in the setting of mult…
Margaret Barton, 83, died of pneumonia complicating rib and pelvic fractures from multiple falls. Critical clinical lessons: (1) The Oxazepam regimen directly contributed to her death. Dr C. tripled her dose from 15mg to…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
LI, a 16-year-old with borderline personality disorder, factitious disorder, and opioid use disorder, died from mixed drug toxicity (codeine, morphine, tramadol, alprazolam, desmethylvenlafaxine) after obtaining prescrip…
57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in cu…
…(1) abnormal ECG results require timely specialist review and follow-up, not rescheduling for 2 years; (2) health alerts must be properly documented and communicated across systems to inform employment suitability; (3) p…
53y · Female·mixed prescription drug toxicity
Deearne Joan Barnes, a 53-year-old woman with complex psychiatric history including depression, OCD, substance abuse disorder, and chronic non-cancer pain, died from mixed prescription drug toxicity involving venlafaxine…
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