92 results for “acute suicidal behaviour”
87y · Female·intentional inhalation of tissue paper leading to upper airway obstruction and h…
…ing unsafe in the chaotic ward environment. The coroner identified several clinical lessons: recognizing behavioural escalation in dementia patients as potentially indicating increased risk (not merely as disease manife…
38y · Male·Exsanguination due to penetration of arm veins
…ealth services. Although reviewed by a mental health nurse specialist on 24 April 2008 who noted fleeting suicidal thoughts but found him future-oriented, no acute risk was identified. Following lockdown on 27 April, Bre…
19y · Female·hypoxic encephalopathy as a result of attempted hanging
A 19-year-old woman with psychosis and depression died from hypoxic encephalopathy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admissions to mental health facilities in a fortnight before his death. Critical clinical l…
31y · Female·Compression of the neck
…when treating both Ms O'Brien and Mr Sturt. On 23 June 2019, despite documented delusions and aggressive behaviour, Mr Sturt was discharged the same night after psychiatric assessment that appeared to minimise family vi…
18y · Female·Mixed drug toxicity
…disorder, died from mixed drug toxicity after intentionally overdosing on propranolol while admitted to an acute mental health unit under involuntary treatment. She had a documented history of medication stockpiling and…
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
…ad consumed cannabis and alcohol that evening and upon return to care at approximately 2.55am, experienced acute psychotic symptoms (hearing voices). She became aggressive, assaulted her carer, then locked herself in he…
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …
25y · Female·Chest injuries due to fall from height
…isk assessment was conducted despite clinical deterioration postpartum. AW spent 462 days in an unsuitable acute ward, developed severe alcohol dependence unchecked by behavioural management, and died on the day of a Me…
41y · Male·complications in association with effects of fire, with terminal palliative care
…Graylands Hospital on 29 October 2021 following a 12-day admission for management of psychosis and recent suicidal behaviour (drain cleaner ingestion). Key deficiencies included: failure of discharging psychiatrist to di…
18y · Male·acute neck compression due to hanging
Shane Blunden, aged 18, died by hanging in Yatala Labour Prison on 19 September 2011. He was a remanded prisoner with an extensive history of self-harm, including cutting, swallowing batteries and razors, and a previous …
asphyxia sequential to hanging (all three cases); Charles Barlow: schizophrenia …
Three linked suicide cases spanning February 2004 to October 2005 in Far North Queensland mental health services. Charles Barlow (36, Aboriginal) was denied admission despite requesting transfer to Cairns Base Hospital M…
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