264 results for “conduct disorder”
31y · Female·Compression of the neck
Caitlin O'Brien, a 31-year-old nurse, was murdered by her intimate partner Shea Sturt via compression of the neck on 25 June 2019. The coroner identified multiple systemic failures in family violence recognition and risk…
50y · Male·Multiple injuries as a result of being struck by a train
A 50-year-old ICU nurse at Cabrini Hospital died by suicide by stepping in front of a train after experiencing a cascade of adverse events. In October 2009, he attended work while intoxicated following personal stress, l…
63y · Male·Aspiration pneumonia in the setting of functional decline in a man with an intel…
A 63-year-old man with intellectual disability, cerebral palsy, dysphagia, and COPD died from aspiration pneumonia following functional decline. He had a three-month hospital admission with multiple complications includi…
58y · Male·blunt force head injury
Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included p…
Multiple stab wounds to chest (David Gerard: stab wound to chest piercing heart;…
Joint inquest into two homicides by individuals with schizophrenia who were managed by mental health services. Anthony Butler stabbed David Gerard in 2001 after being discharged from Glenside Hospital without Community T…
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…
34y · Male·drowning
A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community…
5y · Female·disseminated candidiasis secondary to protein-energy malnutrition
…nutrition and unreasonable delay in seeking medical care directly caused the death. Healthcare providers' conduct was not criticized.
40y · Male·Injuries sustained in a fall from height
Daniel McKindley, 40, died from injuries sustained in a fall from the 16-metre platform of Poppet Head Lookout tower in Bendigo. He had depression and anxiety treated by his GP with antidepressants (mirtazapine then sert…
23y · Male·Hanging whilst suffering acute mental illness, most likely a first episode delus…
…creening Unit and remained in protective custody in isolation. Critical deficiencies included: failure to conduct mandated daily nursing observations in protective custody; inadequate clinical handover when the assessin…
34y · Male·self-inflicted hanging
…ot grant leave to actively psychotic involuntary patients outside recovery-phase discharge planning, must conduct thorough pre-leave risk discussions with carers away from the patient, and ensure documented conditions a…
46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)
…, Gavin Lyle Woods, died by suicide after prolonged workplace stress and an undertreated major depressive disorder. He had been a deputy principal at Burpengary State School for only five months. Clinical lessons include…
34y · Male·asphyxiation by hanging
A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …
45y · Female·aspiration of vomitus with bowel obstruction due to faecal impaction
Vicki Margaret Greeuw, a 45-year-old woman with schizoaffective disorder, died on 13 May 2007 at Albany Regional Hospital from aspiration of vomitus secondary to bowel obstructio…
18y · Male·Multiple injuries due to impact by train
…deine overdose following relationship breakdown. Clinical lessons include: (1) CATT clinician should have conducted face-to-face review rather than telephone; (2) psychiatrist should have read referral notes and been in…
68y · Female·Cardiomyopathy with atrial fibrillation, pulmonary hypertension, and alcohol int…
Margaret Brown, a 68-year-old woman with significant cardiac disease (cardiomyopathy, atrial fibrillation, pulmonary hypertension) and chronic alcohol abuse, died at home from cardiomyopathy with alcohol intoxication as …
45y · Female·Compression of the neck in circumstances of hanging
…in an organisationally toxic workplace. Within weeks she became severely distressed with major depressive disorder and insomnia. Despite clear evidence of acute distress on 15 March 2018 (a breakdown at work), she return…
75y · Male·Unascertainable due to advanced decomposition; likely lung cancer
…up by the hospital palliative team after Silver Chain withdrawal; failure to involve housing authority or conduct welfare checks despite clear vulnerability markers (unpaid utilities, uncollected mail); and no systemati…
64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…
Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…
33y · Male·Gunshot wound to the head
A 33-year-old man with paranoid schizophrenia, polysubstance dependence (amphetamines/cannabis), and chronic suicidal ideation died from a self-inflicted gunshot wound to the head. He had been prescribed risperidone and …
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.