391 results for “psychiatric medication management”
53y · Female·Multiple injuries sustained in a fall from height
…on a Community Temporary Treatment Order (CTTO). Despite psychiatrist attempts to increase antipsychotic medication, she declined dose changes. On 16 May 2024, while under community mental health supervision, she fell fr…
28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…
… to guidelines requiring 2-hour intervals) and later midazolam. Combined effects of prolonged restraint, medications with synergistic respiratory depression, obesity, and his violent resistance led to respiratory arrest.…
68y · Male·Bronchopneumonia in a man with chronic obstructive pulmonary disease
…, and undiagnosed pancreatic adenocarcinoma, died from bronchopneumonia. He was a long-term involuntary psychiatric inpatient resistant to treatment and management. His mental health issues substantially complicated med…
53y · Male·asphyxia due to upper airway occlusion by a foreign body (blanket)
A 53-year-old man with complex psychiatric disorder (schizophrenia, depression, intellectual disability) died by asphyxiation after stuffing a bla…
41y · Male·atropine toxicity
…y after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been discharged from psychiatric hospital on a community treatment order with 17-hour daily carer support. The deceased self-administere…
37y · Male·Acute Aspiration Pneumonitis following on Quetiapine Ingestion
…d at St Bartholomew's hostel on the understanding he would self-medicate. Mental health staff restricted medication amounts initially due to concerns about impulsive overdosing, but on 1 November 2002, after a positive p…
24y · Male·aspiration of gastric contents due to or as a consequence of drug toxicity follo…
…rom aspiration of gastric contents due to drug toxicity after ingesting approximately 150 tablets from a medication drawer beside his bed. Andrew had a complex psychiatric history including schizophrenia, multiple suicid…
15y · Male·Mixed drug toxicity (morphine, 7-aminoclonazepam, fluoxetine, sertraline)
…disorder, and chronic sleep disturbance, died from mixed drug toxicity after ingesting his grandmother's medications (morphine, benzodiazepine, sertraline) while fluoxetine remained in his system. He had been placed in h…
65y · Female·Early bronchopneumonia and hypoxic brain injury following aspiration of food (ch…
…5-year-old woman with treatment-resistant schizophrenia, died from aspiration choking while eating on a psychiatric ward. She had been recently transferred to a rehabilitation unit for reassessment of her complex medica…
27y · Male·Combined drug toxicity (heroin, methadone, diazepam and amphetamines)
…olice custody for public intoxication. He was treated for alcohol withdrawal and managed as a voluntary psychiatric patient, with his mood improving during a 27-day admission. He was discharged with appropriate planning…
42y · Female·Incised injury to the neck
… woman with depression and suicidal ideation died by self-inflicted neck laceration while admitted to a psychiatric inpatient unit. She had been assessed as low risk and placed on 30-minute observations. Clinical manage…
30y · Male·neck compression
…ns instructing self-harm, recent suicide attempts, and polysubstance abuse. Despite appropriate clinical management by Forensicare including medication, psychiatric reviews, and placement in a high-observation unit follo…
34y · Female·Dothiepin toxicity in a setting of post-natal depression
…ring hospitalisation and ECT. Anticipating recurrence with her second pregnancy, she proactively sought psychiatric care from Dr D., who prescribed dothiepin (Prothiaden), a cardiotoxic tricyclic antidepressant, at esca…
32y · Female·Mexiletine toxicity
…akness. The neurology team failed to notify her psychiatrist, Dr C., of her admission despite her known psychiatric history and her visibly depressed and anxious presentation immediately prior to discharge. She discharg…
54y · Male·Neck compression (hanging)
Paul Peterson, 54, died by hanging after leaving a private psychiatric hospital on unapproved leave while on close observations. He was admitted with major depression, suicid…
40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…
…essons include: (1) failure to assess and manage seizure risk despite clear indicators (recent seizures, medication non-compliance, 72-hour sleep deprivation); (2) inappropriate application of a community mental health m…
19y · Female·hypoxic encephalopathy as a result of attempted hanging
…chosis and depression died from hypoxic encephalopathy following attempted hanging while in involuntary psychiatric admission. She was on R15 (15-minute) observation status due to suicide risk, but observations were not…
42y · Male·Upper airway obstruction (choking) in an obese man with atherosclerotic heart di…
…m upper airway obstruction (choking) on food while dining at home. He had been recently discharged from psychiatric inpatient care on a Community Treatment Order with a stable medication regimen including quetiapine, so…
57y · Male·Multiple injuries sustained by being struck by a freight train
…th 28-year history of treatment-resistant schizophrenia died by suicide when he absconded from an acute psychiatric unit and stepped in front of a train. Despite comprehensive psychiatric management including regular ps…
Female·early bronchopneumonia complicating combined drug toxicity (fentanyl overdose)
Wendy Osborne, a woman with a history of substance abuse and psychiatric issues, died from bronchopneumonia complicating fentanyl overdose. Her GP prescribed fentanyl patches (…
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