161 results for “polysubstance use”
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
28y · Male·Hanging
…ssion—he was discharged home with inadequate safety planning. Clinicians did not fully explore Dylan's drug use timeline, did not contact his girlfriend, did not provide written safety plans, and failed to adequately in…
48y · Male·Coronary artery atherosclerosis in the setting of immersion
… inform boating decisions; (4) emergency communication protocols need clarity on location-sharing; (5) polysubstance use in high-risk activities warrants assessment.
23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…
A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric disch…
36y · Male·Hanging
A 36-year-old male prisoner with complex psychiatric history, substance use disorder, and recent cancer diagnosis died by hanging in prison. Recent mental health assessments (within 3…
30y · Male·pulmonary thromboembolism in an overweight man with comorbidities (including rec…
Karl Steinhauser, a 30-year-old man with schizoaffective disorder and polysubstance misuse, died from pulmonary thromboembo…
29y · Male·unknown, probably immersion
… Flanders, a 29-year-old man with a complex psychiatric history including personality disorder, substance abuse, previous suicide attempt, and drug-induced psychosis, disappeared on 28 January 2016 after being released …
53y · Male·Gunshot wound to the left thigh with transection of femoral artery and vein; exs…
…re appears related to either patient manipulation or equipment issues with the MAT tourniquet model then in use; ambulance protocols should ensure constant visual monitoring of tourniquets without covering them; and the…
48y · Male·gunshot wound to chest
… untreated mental health conditions (PTSD, borderline personality disorder, chronic suicidality), substance use, and easy access to a realistic gel blaster as contributing factors. The coroner recommended legislative am…
27y · Male·Multiple gunshot wounds
…. Critical clinical lessons include: early identification of escalating mental health crises with substance use; importance of comprehensive follow-up after acute psychiatric presentations; risk assessment in the contex…
46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis
Jason Mallett, a 46-year-old man with bipolar affective disorder and schizo-affective disorder, died from cardiac arrhythmia secondary to coronary arteriosclerosis and myocarditis while an involuntary psychiatric patient…
25y · Male·consistent with drowning in a man with multiple injuries
…and Treatment Team (CATT) revealed suicidal ideation with plan, paranoid delusions, and recent illicit drug use. He was admitted to the Low Dependency Unit (LDU) rather than the High Dependency Unit despite documented h…
14y · Female·ligature compression of the neck (hanging)
Child RK, aged 14, died by suicide while in Department of Communities care at a therapeutic residential group home on 20 April 2022. She had Complex PTSD from childhood trauma and presented multiple times to emergency de…
33y · Male·sharp force injuries of the neck
Malcolm Brown, a 33-year-old Aboriginal man with a history of methamphetamine use, mental health crisis, and self-harm threats, died from sharp force injuries to his neck on 29 June 2022 fo…
47y · Female·ligature compression of the neck (hanging)
…ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior self-harm attempts. While physical health care was adequate, mental health…
17y · Female·ligature compression of the neck (hanging)
…ng discharged from secure care. She had experienced complex developmental trauma, family violence, sexual abuse, and severe alcohol-related liver disease. Critical gaps were identified in the child protection system: th…
31y · Male·Hypoxic encephalopathy caused by neck compression due to hanging
… failures included: delayed transfer to appropriate specialist care due to administrative error; failure to use Mental Health Act powers to compel medication when he was clearly psychotic and treatment-resistant; inadeq…
28y · Male·Overdose of Clozapine
A 28-year-old man with schizophrenia and substance abuse history died from clozapine overdose. Key clinical failures included: inadequate assessment of suicide risk…
27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…
…. Critical clinical and system factors in Tafari's case (22 years old, mental health disorder, substance misuse) were inadequately managed: he admitted drug use on parole but was not subjected to mandatory drug testing;…
41y · Male·ligature compression of the neck (hanging)
Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 Augus…
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