77y · Male·respiratory failure caused by severe pneumonia
Ronald Allen Hampton, aged 77, died from respiratory failure due to severe pneumonia while detained under the Mental Health Act at Glenside Hospital. He had been admitted with behavioural disturbances related to dementia…
74y · Male·disseminated carcinoma (widespread cancer); specifically haemorrhage into right …
Ronald Smallwood, a 74-year-old man with chronic paranoid schizophrenia and renal cancer, died in hospital from disseminated carcinoma. The key clinical lesson relates to institutional knowledge rather than direct patien…
58y · Male·hanging
A 58-year-old man remanded in custody awaiting trial died by hanging in prison. He had a history of depression treated with fluoxetine and was assessed by a forensic psychiatrist who found no evidence of depression or su…
81y · Female·respiratory arrest caused by bronchopneumonia contributed to by non-Hodgkin's ly…
An 81-year-old woman with dementia and non-Hodgkin's lymphoma died of respiratory arrest caused by bronchopneumonia while detained at a mental health facility. She was admitted to Glenside Hospital in November 1999 and t…
76y · Male·pneumonia
A 76-year-old man with dementia, detained under the Mental Health Act at Glenside Hospital, died of pneumonia. He had multiple comorbidities including congestive cardiac failure and irregular pulse. On 3 November, his pn…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…
56y · Female·Bronchial asthma and emphysema
A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…
54y · Male·Unknown - death established on balance of probabilities but manner and cause und…
A 54-year-old man with major depressive disorder, chronic suicidality, and alcohol abuse was discharged from psychiatric hospital on 23 April 2014 while remaining at "very high chronic suicide risk." He had multiple prio…
45y · Male·Coronary Atherosclerosis
David Grieve, a 45-year-old man with chronic schizophrenia and multiple cardiac risk factors (hypertension, diabetes, obesity, smoking), died of coronary atherosclerosis while an involuntary psychiatric patient at Grayla…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
33y · Male·Cerebral haemorrhage
A 33-year-old man with Lowes syndrome (rare genetic disorder causing intellectual disability, blindness, epilepsy, and feeding difficulties) died from cerebral haemorrhage while in supported accommodation. He had been re…
32y · Female·Aspiration pneumonia with severe cerebral palsy as underlying condition
Ella Hitchen was a 32-year-old woman with severe cerebral palsy, quadraplegia, intellectual disability, vision impairment, epilepsy and dysphagia who died from aspiration pneumonia. She had a PEG tube inserted in 2011 du…
55y · Male·Ascending cholangitis due to choledocholithiasis
A 55-year-old man with Down syndrome died from ascending cholangitis due to choledocholithiasis following recurrent biliary sepsis. He had multiple comorbidities including Alzheimer's disease, depression, and cardiac dys…
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