264 results for “conduct disorder”
40y · Male·compression of the neck due to hanging
Brian Pope, a 40-year-old man with longstanding mental health issues including major depressive disorder, anxiety, learning disability (dyslexia), and substance abuse history, died by suicide in prison 20 days …
50y · Female·Hanging
…017. Despite supportive interventions from senior judges and mental health treatment for major depressive disorder, she resigned in July 2017 and died by suicide in October 2017. The coroner found medical care was approp…
24y · Male·multiple injuries and chest compression asphyxia (train strike)
…in strike on 2 June 2020, two days after release from remand custody. He had schizophrenia, substance use disorder, and was recently incarcerated for assault and FVIO breach. While in prison, Bryan displayed bizarre beha…
22y · Male·Hanging
Timothy John, age 22, died by hanging 8 days after commencing varenicline (Champix) for smoking cessation. He had a documented history of depression, anxiety, and substance abuse, with prior attempted suicide. His GP, Dr…
30y · Male·Gunshot wounds to the chest
Gabriel Messo, a 30-year-old man with bipolar affective disorder, died from gunshot wounds inflicted by Victoria Police on 16 July 2020 after violently assaulting his mot…
28y · Male·neck compression subsequent upon hanging
Matthew Spalding, a 28-year-old psychiatric inpatient with borderline personality disorder and recent psychotic symptoms, died by hanging on 25 April 2009. He had been admitted to the Adult Acute …
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
…res included inadequate communication protocols, poor knock-up system audio quality, failure of rovers to conduct proper cell checks, and systemic under-resourcing of mental health services in correctional facilities.
24y · Male·Hypoxic brain injury secondary to hanging
BJ, a 24-year-old with paranoid schizophrenia, substance abuse disorder, and anti-social personality disorder, died by hanging in a psychiatric unit after a suicide attempt. He …
15y · Male·Neck compression due to hanging
Yakamurro, a 15-year-old First Nations boy in Territory Families care, died by hanging in NSW in December 2018. The coroner found multiple systemic failures contributed to his death. Key failures: inadequate family consu…
34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…
…ve warnings from Monash Health that she required psychiatric assessment before any leave. She had bipolar disorder, borderline personality disorder, Type 1 diabetes, and was pregnant (28 weeks). Within hours of discharge…
27y · Female·neck compression (suicide by hanging)
… fear for her safety, and excessive alcohol consumption (blood alcohol 0.240%). The coroner found Chris's conduct toward her—including documented physical violence, emotional abuse, and controlling behaviour in late Feb…
26y · Male·Neck compression from hanging
…died by hanging in his correctional centre cell on 26 October 2011. He had a history of mixed personality disorder, anxiety, opiate dependence and previous suicide attempt (age 13), but was not assessed as 'at risk' at t…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
18y · Female·asphyxiation and respiratory failure on a background of severe dystonic quadripl…
…t a pillow wedged against the bed rail. The coroner found the critical clinical lesson was the failure to conduct regular morning checks, which might have detected her distress or compromised state and enabled life-savi…
24y · Female·hypoxic brain injury secondary to hanging
Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…
Constable Arnold: single gunshot wound to the chest. Constable McCrow: gunshot w…
…Gareth, Stacey, and Nathaniel Train) died on 12 December 2022. The Trains suffered from shared delusional disorder characterised by persecutory beliefs, anti-government views, and end-times religious ideology. Four const…
27y · Male·traumatic rupture of the mid brain complicating ring fracture of the skull base
…he skull base after his vehicle collided with trees while evading police. The death was not due to police conduct; officers appropriately terminated pursuit when risks became excessive. However, critical systemic failur…
31y · Male·ligature compression of the neck (hanging)
Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted suicide by wrist-cutting on 30 March 2022 and th…
54y · Female·unascertained
…fore leave; (3) Knowledge of patient's prior absconding history should inform risk assessment; (4) Eating disorder services require multidisciplinary coordination from admission; (5) Family should be consulted for releva…
14y · Male·gunshot wound to the head
… an acknowledged alcoholic, and had no control over Andrew. The relative carer assessment was inadequate, conducted without observing child-carer interaction or consulting Andrew's wishes. When Andrew went missing in ea…
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