113 results for “serious mental illness”
48y · Male·Hanging (partially suspended hanging using shoelaces as ligature)
Robert Harold Gerard, aged 48, died by hanging in Risdon Prison in May 2022 while on remand for serious charges. He had paranoid schizophrenia, a long history of substance abuse, and was experiencing depressio…
Male·David Gurralpa: sudden heart attack (coronary atherosclerosis with long-standing…
…e-escalation strategies, or respond to medical staff warnings. Inadequate training on positional asphyxia, mental illness management, and handover procedures between police and hospitals were identified as systemic failu…
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
…tween Justice Health and Corrective Services, and in medication management for incarcerated patients with serious illness. The coroner recommended amending the Health Problem Notification Form to include explicit prompt…
41y · Male·Gunshot wounds to neck and chest (perpetrator Joel Cauchi); stab wounds (six vic…
…Good, Faraz Tahir, and Pikria Darchia. Cauchi was shot and killed by police. The inquest examined Cauchi's mental health management in Queensland before the attack. Key clinical failures identified: (1) gradual cessation…
49y · Male·hanging
… a complete picture of his vulnerability. The coroner found the officers could not reasonably have invoked mental health detention powers based on his presentation alone, but the failure to update LEAP denied them the co…
37y · Male·self-inflicted gunshot wound to the head and neck
…ces Officer Harvey and shot himself. Lothian had a history of depression, substance abuse, and was facing serious charges with limited prospects of escape from his legal predicament. The coroner identified multiple syst…
36y · Female·Nicotine toxicity
…, depression, anxiety, and agoraphobia, ingested liquid nicotine at home on 22 November 2017 after calling mental health triage expressing suicidal intent. The clinical lessons relate to the response to acute suicide ris…
49y · Male·incised injury to the neck
…5 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health assessment and crisis response. On 5 August, psychiatric assessment in ED correctly followed the Me…
41y · Male·exsanguination (hypovolemic shock complicating acute blood loss) due to fistula …
…ker (Mr Lockwood) found him with facial blood but failed to call an ambulance despite clear indicators of serious illness. The coroner found this decision wrong and that earlier medical intervention would nearly certain…
45y · Male·Gunshot injury to the chest (self-inflicted)
…on despite negative investigations. He declined medication and became preoccupied with the possibility of serious illness. In the weeks prior to his death, he appeared withdrawn but not obviously suicidal to colleagues …
31y · Male·self-inflicted hanging
…l man, died by self-inflicted hanging in Darwin Correctional Centre on 30 August 2021. He was remanded on serious charges and initially placed 'at risk' following his court appearance. A mental health assessment on 14 J…
55y · Male·Septicaemia due to hydronephrosis and infection
…lthcare providers misunderstood privacy legislation, limiting their ability to make appropriate referrals; mental health and physical health records were not cross-referenced; and hoarding disorder was not recognised as …
45y · Female·Compression of the neck in circumstances of hanging
…al support from the Court or CSV. She saw multiple doctors seeking rapid solutions but did not disclose a serious suicide attempt. A failed earlier suicide attempt and her obsessional thoughts about workplace failure an…
43y · Male·aspiration of vegetable matter with occlusion of the upper airway
…tric assessment, he was discharged without admission. A critical failure occurred on 24 September when the mental health team's decision to 'await recontact' rather than assertively intervene, despite clear family concer…
23y · Male·Hanging
Majang Ngor, a 23-year-old man in custody at Thomas Embling Hospital's Argyle Unit following arrest for serious criminal offences, died by hanging in a disabled bathroom on 24 June 2013. He was admitted under the Ment…
Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…
…, then took his own life. TBD had experienced multiple police contacts in the preceding weeks, including a mental health assessment on 14 November following serious threats at a pub. The coroner found that while TBD rece…
22y · Male·Immersion in water (drowning) in a man with combined drug effect
…tre, and St John of God Midland Hospital. While clinicians provided appropriate care within constraints of mental health law and his voluntary patient status, several missed opportunities were identified: Dr M. did not r…
52y · Male·Multiple injuries and immersion leading to hypoxic brain injury and pneumonia
… assault. The perpetrator, Y, was a patient with schizo-affective disorder admitted involuntarily to Casey Mental Health Service from 30 December 2008 to 16 January 2009. The coroner examined Y's clinical management and …
31y · Male·Overdose of quetiapine (Seroquel) in combination with alcohol
Travis Graham, a 31-year-old man with a history of mental illness, self-harm, and substance abuse, died from an overdose of quetiapine (Seroquel) combined with alco…
28y · Male·Global cerebral ischaemic injury due to hanging
Rahul Prasad, a remanded prisoner with a serious psychotic condition and documented suicide risk, was discharged from the Acute Assessment Unit on 7 May 2…
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