Coronial

391 results for psychiatric medication management

TAShospital2021-07-26

Coroner's Finding: Sowden, James Robert

65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists

…d features (diagnosed 2003) and autoimmune thyroiditis. In the week before death, he experienced adverse medication effects (paranoia, panic attacks) after being prescribed antidepressants for worsening depression and an…

psychiatryemergency medicinediagnosticcommunicationquetiapine
SAmental health2008-07-17

Coroner's Finding: TARNOWSKI Marek Tomasz

33y · Male·Respiratory failure due to mixed drug toxicity (amitriptyline, oxycodone, morphi…

A 33-year-old man with chronic back pain, depression, morbid obesity and sleep apnoea died in psychiatric custody from respiratory failure due to mixed drug toxicity and probable aspiration. He was heavily med…

psychiatryemergency medicinesystemamitriptyline
VIChospital2014-05-28

Finding into death of Susan Ingrid Robb

37y · Female·Mixed drug toxicity (methadone, diazepam, clonazepam, amisulpride, olanzapine, h…

Susan Robb, 37, was admitted involuntarily to Northern Hospital Psychiatric Unit with deteriorating mental health and on a Community Treatment Order. Three weeks after self-discon…

psychiatryaddiction medicinediagnosticmedicationmethadone
NSW2018-08-31

Inquest into the death of MC

31y · Male·hanging

…d Centre while in lawful custody. He had been transferred to the Mental Health Screening Unit for acute psychiatric care after expressing paranoid ideation at Cessnock Correctional Centre. Critical clinical failures wer…

psychiatrycorrectional healthcommunicationsystemolanzapine
QLDmental health2007-06-20

Liddell, Matthew John

28y · Male·hypoxic encephalopathy secondary to hanging

…t-traumatic stress disorder and depression following the 1998 HMAS Westralia fire, died by hanging in a psychiatric hospital. He had been admitted on 8 November 2003 after separation from his de facto wife triggered acu…

psychiatryemergency medicinecitalopram
VICmental health2015-10-30

Finding into death of Jarrod Wade Christie

23y · Male·injuries sustained when struck by train

Jarrod Christie, 23, a voluntary then involuntary psychiatric inpatient at Maroondah Hospital, absconded from the high-dependency unit on 22 December 2012 and died b…

psychiatrygeneral practicecommunicationsystemdesvenlafaxine
VIChome2021-05-05

Finding into death of Aisha Devi Beck

39y · Female·Gunshot wound to the head

…h psychosis in 2015, treated with olanzapine, and discharged with instructions to continue antipsychotic medication. In March 2016, she relapsed with suicidal and homicidal thoughts, was stabilized by psychiatrist Dr C. …

psychiatrygeneral practicecommunicationsystemolanzapine
TAShome2018-03-15

Coroner's Finding: Vince, Brock

35y · Male·drowning following combined drug and alcohol intoxication

…r, and alcoholism, died by drowning in his bathtub while intoxicated with alcohol and therapeutic-level psychiatric medications. He had sought hospital admission multiple times in the preceding days and was scheduled fo…

psychiatryemergency medicinequetiapine
NSWmental health2022-09-16

Inquest into the death of S B

81y · Male·cardiac arrest following neck compression due to hanging

…c assessments that were delayed or not completed. Critical issues included: inadequate documentation of psychiatric assessments (the consultant conducted no documented comprehensive assessment); failure to clarify the p…

psychiatrygeriatric medicinediagnosticcommunicationolanzapine
VICaged care2025-09-10

Finding into death of IWT

77y · Female·Complications of malnutrition in a woman with paranoid delusions

A 77-year-old woman with complex medical and psychiatric history died from complications of malnutrition while an inpatient with paranoid delusions and delirium…

psychiatrygeriatric medicineolanzapine
SAhospital2017-05-11

Coroner's Finding: ROBINSON Scott Alexander

44y · Male·neck compression consistent with hanging

…Hospital on 1 February 2014. He had been granted ground leave on hospital grounds as part of therapeutic management. Three psychiatrists, including his treating doctor, assessed him as having low suicide risk and he had …

psychiatrypaliperidone
SAhospital2004-02-13

Coroner's Finding: CUCUK Radomir

38y · Male·multi organ failure secondary to intestinal ischaemia from toxic megacolon relat…

…ounds for criticism of medical treatment. However, the case highlights the importance of proactive bowel management in psychiatric patients on constipating medications, particularly those with limited ability to self-rep…

psychiatryemergency medicineclozapine
NSWhospital2023-03-03

Inquest into the death of Irene Charlish

68y · Female·Complications of a fall with contributing factors of respiratory failure, respir…

…was admitted to Ryde Hospital where she refused treatment, became aggressive, and resisted hydration and medication administration. Despite appropriate medical care, she died on 11 June 2017. Expert toxicology review con…

emergency medicinepsychiatryclozapine
NSW2016-03-14

Inquest into the death of Michael David John Nolan

30y · Male·Exsanguination due to an incision in the radial vein of his right wrist

… Services appropriately managed his care during his final weeks, including appropriate risk assessments, medication, and psychiatric reviews. While Nolan was at baseline elevated suicide risk due to his conditions, the c…

psychiatrycorrectional healthmethadone
VICmental health2013-05-10

Finding into death of Michael Desmond McWhirter

79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular …

…s, pacemaker, renal impairment, vascular dementia) died from acute myocardial infarction while in acute psychiatric care. He was transferred to Peter James Centre from general hospital for management of agitation and co…

psychiatrygeriatric medicinecommunicationsystemolanzapine
VIChome2024

Finding into death of B E

50y · Male·Neck compression and hanging

…ith PTSD, depression, and past polysubstance use, died by suicide via hanging. He had been engaged with psychiatric care since 2021, showing improvement with EMDR therapy and medication (escitalopram, medicinal cannabis…

psychiatrygeneral practicecommunicationdelayescitalopram
NThome2018-07-25

Inquest into the death of Paula Schubert

53y · Female·self-inflicted hanging

…s without support persons or adequate notice. Simultaneously, her psychiatrist reduced her antipsychotic medication and transitioned her abruptly to GP care without proper planning, leaving her feeling abandoned. The psy…

psychiatrygeneral practicecommunicationsystemrisperidone
QLDhospital2007-09-03

Henderson, Robert Joseph

31y · Male·mixed drug toxicity

… his case manager appropriately identified escalating violence, substance abuse, and non-compliance with medication. However, he absconded from the psychiatric ward the next morning before psychiatric review. Critical cl…

psychiatryemergency medicinediagnosticdelaymorphine
VIChome2017-02-22

Finding into death of KD

56y · Male·Aspiration of gastric content secondary to combined drug toxicity

…ne over years without adequate oversight or specialist coordination. One GP mistakenly believed ongoing psychiatric supervision was occurring when contact had ceased in 2011. The other GP knew psychiatric care had ended…

general practicepsychiatrycommunicationsystemdiazepam
WAmental health2001-02-02

Inquest into the Death of Giovanni Mario Franco

30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology

…inal admission in February 1998, he developed severe behavioural disturbance resistant to anti-psychotic medication, progressing to medication-induced delirium. He was treated with multiple anti-psychotic agents, includi…

psychiatryintensive caremedicationflupenthixol decanoate
145620

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