113 results for “serious mental illness”
62y · Male·extensive small cell lung cancer
…d 62, died from extensive small cell lung cancer at Royal Adelaide Hospital on 18 March 2011. He was under Mental Health Act detention when he developed delusions and delirium during his final illness. The coroner found …
36y · Male·Alcohol toxicity from consumption of Listerine mouthwash
… consumption of a 1-litre bottle of Listerine mouthwash. He was an involuntary patient at Bridgeview House mental health unit when found unresponsive at 7am on 15 December 2014. Nursing observations every 2 hours showed …
16y · Male·Gunshot wound to the head
…olescents—at age 11, the focus was on psychosocial stressors rather than diagnosing underlying depressive illness; (2) explicit inquiry about access to means of suicide, particularly firearms, when patients disclose sui…
17y · Male·Diabetic ketoacidosis
…estigation. Paramedics failed to recognise the constellation of vital sign abnormalities as indicative of serious illness, were influenced by cognitive bias from the recent GP diagnosis, and did not perform basic invest…
45y · Female·haemorrhage due to traumatic rupture of the liver
…r cutting her wrist deeply with a carving knife. The treating casualty officer did not properly document a mental state examination, failed to detect signs of active psychosis (auditory hallucinations), and did not detai…
27y · Male·cardiac arrhythmia during restraint; mechanism involved hypoxia and asphyxiation…
… catecholamines during struggle and restraint. The coroner found the death was by misadventure but raised serious concerns about restraint training, procedural safety, and inadequate monitoring of access to alcohol and …
75y · Male·Burns
…l ignition from a dropped cigarette, fire investigation evidence—including burn pattern analysis and experimental testing—indicated the fire originated at his trouser legs, consistent with deliberate ignition. Key clinic…
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
Joint inquest into two homicides by individuals with schizophrenia who were managed by mental health services. Anthony Butler stabbed David Gerard in 2001 after being discharged from Glenside Hospital…
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
Maris Kugis, a 68-year-old man with chronic schizophrenia, personality disorders, and multiple serious physical conditions including COPD, ankylosing spondylitis, and undiagnosed pancreatic adenocarcinoma, di…
28y · Male·hanging
…th treatment-resistant paranoid schizophrenia and substance abuse died by hanging while detained under the Mental Health Act in a closed psychiatric ward. He had chronic auditory hallucinations commanding self-harm and h…
45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…
Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thiorid…
52y · Male·atherosclerotic and hypertensive heart disease
…ventive health screening including blood pressure monitoring, cholesterol and lipid testing, and ECGs. His mental health team appropriately maintained him on a CTO to ensure medication compliance after previous relapses …
44y · Male·Positional asphyxia
…y flexed. Key clinical lessons: unsafe medication handling and sharing of controlled antipsychotics poses serious risk; combination of alcohol with clozapine and cannabis caused profound CNS depression; patients with me…
16y · Male·Multiple blunt traumatic injuries from fall from height
A 16-year-old boy with depression and suicidal ideation was discharged from an inpatient adolescent mental health facility in Victoria after 20 days. Two days later, he died by suicide at a cliff location he had p…
27y · Male·external blood loss due to laceration of right axillary artery from single gunsh…
…n 12 May 2004 (when appearing incoherent and paranoid) was deemed appropriate. However, the coroner found serious police operational failures: Sergeant Cahir single-handedly confronted an armed, drug-affected man in a b…
39y · Female·gunshot wound to the head
…buse, and surveillance. Psychiatric evaluation concluded Floyd likely suffered from Delusional Disorder—a serious mental illness characterised by fixed false beliefs despite contrary evidence. While Floyd engaged with G…
49y · Male·small intestinal infarction due to mesenteric and portal vein thrombosis associa…
… banding. On 19 October 2003, he became delirious and agitated, leading to involuntary detention under the Mental Health Act. He was found unresponsive at 6:15am and died despite resuscitation. The coroner found his clin…
60y · Male·burn wounds and the consequences thereof
…ng relapse. His GP assessed him on 8 and 15 September but did not recognise the escalating severity of his mental state, accepting benign explanations for his behaviour and not scheduling him for involuntary assessment d…
72y · Male·Multiple stab and incised wounds to the chest and neck
…ere identified: the Community Corrections pre-sentence assessor lacked information about Woodruff's recent mental illness diagnosis and psychiatric referral; Forensicare's referral to Peninsula Health Mental Health Servi…
Deaths from injuries sustained in a mass stabbing attack
…eatment-resistant schizophrenia and had ceased antipsychotic medication. Key clinical findings identified serious deficiencies in psychiatric care, including inadequate management of medication cessation, poor coordinat…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.