918 results
26y · Male·respiratory arrest complicating hydrocarbon inhalation (sudden sniffing death)
A 26-year-old man with schizophrenia, antisocial personality disorder, and polysubstance abuse died from sudden sniffing death syndrome after inhaling fly spray in a psychiatric ward smoking room. Three days prior, staff…
18y · Female·hypoxic encephalopathy due to raised intracranial pressure caused by severe clos…
An 18-year-old woman died from hypoxic encephalopathy due to severe closed head injury sustained when she fell from a shade sail structure at a playground. While climbing on the sail with friends after consuming minimal …
69y · Female·Respiratory obstruction by aspirated food (Brussels sprout, chicken and carrots)…
Helena Czekajlo, aged 69, died from respiratory obstruction by aspirated food (Brussels sprout) at a nursing home. She had dementia and schizophrenia with a documented obsession about food and tendency to eat hurriedly. …
1y · Male·neck compression due to hanging from curtain cord
A 15-month-old boy died from neck compression caused by entanglement in a curtain cord while sleeping in his cot. The cord, used to close nearby curtains, became wrapped around his neck despite the mother's belief it had…
62y · Female·ventricular fibrillation associated with congestive cardiomyopathy
A 62-year-old woman detained under the Mental Health Act for acute psychiatric deterioration (psychosis, confusion, paranoia) secondary to anxiety following cardiomyopathy diagnosis died from ventricular fibrillation ass…
68y · Female·glottic obstruction by food bolus
A 68-year-old woman with Huntington's disease, schizophrenia, and schizoaffective disorder died from glottic obstruction by food bolus while eating breakfast in a psychiatric hospital where she was detained under the Men…
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…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
41y · Male·closed chest injuries (ruptured hemi-diaphragm with displacement of abdominal co…
Trevor Coppins, a 41-year-old plant operator, died from closed chest injuries sustained when a road roller he was operating failed to brake while reversing down a steep hill and overturned. Investigation revealed the bra…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
77y · Female·myocardial infarction
Eileen Sarah Elliott, aged 77, died of myocardial infarction following a fall and leg fracture in January 2000. She was admitted to Glenside Hospital under a Mental Health Act detention order for chronic schizophrenia. A…
43y · Female·sepsis secondary to extensive acute peritonitis following perforation of small b…
43-year-old woman died from sepsis and necrotising fasciitis following small bowel perforation during laparoscopic tubal ligation. She was at high risk due to previous abdominal surgeries and adhesions. A 4-5mm perforati…
82y · Male·Lateral left ventricular myocardial infarction attributed to severe left circumf…
An 82-year-old man with severe chronic obstructive airways disease and dementia died of acute myocardial infarction while detained under mental health legislation in a secure psychiatric ward. He had been given clonazepa…
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…
37y · Male·Multiple injuries including lung lacerations and contusions, multiple rib fractu…
Andrew Grant Baulderstone, aged 37, died from multiple injuries when refractory material collapsed from the lining of a pellet kiln at BHP's Whyalla plant while he was jackhammering. The collapse resulted from failures i…
39y · Female·neck compression due to hanging
A 39-year-old woman with bipolar disorder, depression, substance abuse (alcohol and cannabis), and multiple past suicide attempts died by hanging at home on 11 February 1998. She had been discharged from psychiatric hosp…
19y · Male·heroin toxicity
Marshall Carter, 19, died in custody from heroin toxicity at Yatala Labour Prison. He had a long history of drug abuse starting from age 14 and was an intravenous heroin user. Critical failures included: inadequate trans…
38y · Male·neck compression due to hanging
Michael Andrew Curren, a 38-year-old prisoner at Mobilong Prison, died by hanging on 10 June 1998. He had been assaulted five days earlier and attended medical review on the day of death, but presented as being in good s…
30y · Male·cardiac arrhythmia due to therapeutic clozapine use
Edmund James Fern, aged 30, died at a psychiatric institution (James Nash House) on 4 September 1997, nine days after septoplasty for nasal obstruction. He was on multiple medications including clozapine 350mg nightly, c…
26y · Male·neck compression due to hanging
A 26-year-old Aboriginal man with longstanding borderline personality disorder, substance abuse, and multiple suicide attempts died by hanging in a psychiatric ward whilst detained under a Mental Health Act order. Key cl…
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