181 results for “poor medication compliance”
33y · Male·ketoacidosis, likely alcoholic ketoacidosis
…res were identified. The cause was likely alcoholic ketoacidosis, possibly complicated by non-prescribed medications and internet-sourced insulin. While Mr Martin was a complex patient with comorbid mental illness and su…
48y · Female·Head injury
…he coroner found the quality of care was objectively unsatisfactory due to lack of formal risk assessments, poor family communication, gaps in community care, a Department of Health smoking prohibition policy forcing pat…
64y · Male·bronchopneumonia in a man receiving palliative care for terminal cancer of the r…
…e of treating patients with severe mental illness and comorbid terminal cancer who lack insight and lack compliance.
31y · Male·Burns
…ng schizophrenia was found threatening self-immolation after consuming alcohol and missing antipsychotic medication. Despite police de-escalation attempts, he doused himself with petrol while holding a cigarette lighter.…
35y · Female·neck and chest injuries and drowning due to intentional fall/jump from Tasman Br…
…Tolosa Street Centre, a mental health inpatient facility, receiving appropriate specialist care, regular medication review, and rehabilitation support. The coroner found no deficits in her care or treatment. Her suicide …
79y · Male·Head and neck injuries from blunt force trauma
…osed to family members; inadequate risk assessments at discharge from Werribee Mercy Hospital in June 2013; poor information-sharing between mental health and aged care services; and failure to recognize family violence …
89y · Male·Complications in association with a gastrointestinal illness in an elderly man w…
…ith acute renal failure. While medical care at Casuarina Prison was generally appropriate, there was one medication error: an 18-unit insulin dose administered instead of the prescribed 9 units on 11 September 2021. Expe…
25y · Male·hanging
…nsultation, he did not engage with recommended psychological therapies and appeared focused on obtaining medication for a bipolar disorder diagnosis he did not have. The coroner found his death was not preventable, notin…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
…ns after Forensic Order revocation; inadequate follow-up with six-week gap without face-to-face contact; medication changes (cessation of clozapine) without proper safeguards; and poor coordination between treating teams…
36y · Male·Multi-organ failure complicating injecting drug use
…ischarge, only telephone contact with his mother; (2) lack of direct communication with his GP regarding medication changes; (3) insufficient documentation of his psychotic content and risk assessment during admission. T…
47y · Male·Hanging
… and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations that he self-treated with daily alcohol use. Mu…
65y · Male·Exact cause undetermined; likely drowning, injury, or medical emergency while sa…
…ies by patients with chronic medical conditions require risk assessment; mood changes and increased pain medication use warrant mental health evaluation; safety equipment compliance should be encouraged regardless of pat…
30y · Male·ligature compression of the neck (hanging)
…ments; and failure to provide family with basic safety information about post-discharge vulnerability. A medication change occurred four days prior to discharge despite fluctuating mental state. The deceased was not dete…
36y · Female·Effects of fire and stab wounds (Kylie Fowler); effects of fire (Melanie Maher);…
Kylie Fowler, a 36-year-old woman with severe schizophrenia and a 18-year history of involuntary psychiatric admissions, killed her three children (Samantha 18, Melanie 13, Matthew 11) and herself by stabbing and fire on…
36y · Female·head injury
…d opportunities in mental healthcare management. Key failures included: cessation of antipsychotic depot medication in April 2017 without adequate monitoring plan; failure to review historical clinical records documentin…
58y · Male·Gastrointestinal haemorrhage due to erosive gastritis
…nd acute gastrointestinal bleeding. Resuscitation was deemed inappropriate given his massive aspiration and poor prognosis. The coroner found death arose from natural causes and that supervision, treatment, and care were…
Deaths from injuries sustained in a mass stabbing attack
…l 2024. The perpetrator, Joel Cauchi, had treatment-resistant schizophrenia and had ceased antipsychotic medication. Key clinical findings identified serious deficiencies in psychiatric care, including inadequate managem…
27y · Male·Combined drug toxicity (heroin, methadone, diazepam and amphetamines)
…ioner requesting methadone for recent illicit substance use but did not disclose his current psychiatric medications or recent hospitalisation. He commenced methadone while continuing to use heroin, benzodiazepines, and …
36y · Male·Shotgun wound to the head
KE was a 36-year-old with longstanding psychiatric history including borderline personality disorder, substance abuse, and multiple previous self-harm incidents. He was on bail with a residential condition preventing him…
Male, female, male, female·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
…ines without safety controls, inadequate clinical assessments and reviews, absent urine drug screening, and poor record-keeping. Dr J.'s negligent prescribing directly caused deaths of Brown and Winwood from combined dru…
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