166 results for “acute traumatic death”
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
… suicidal intent the night before but this was inadequately explored and documented. The coroner found his death was tragic and likely unforeseeable, but identified systemic failures: inadequate Aboriginal liaison offic…
16y · Female·Mixed drug toxicity
…e were inadequate checks on Maria's associations. The coroner found no single measure would have prevented death but highlighted lost opportunities for intervention—better staffing ratios, knowledge of crisis plans, pro…
29y · Male·Hanging
…with Aboriginal communities and failure to escalate the evening call response contributed to a preventable death.
58y · Female·Complications of poorly controlled type 2 diabetes
… (Individual Support Worker) since 2005. Critical deficiencies included: no ISW visits for 7 months before death; no home monitoring of her diabetes despite demonstrated inability to self-manage; irregular contact with …
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…
…izoaffective disorder and substance use was admitted involuntarily to the Kiloh Centre after presenting in acute psychosis with suicidal ideation on 1 April 2017. His psychotic symptoms rapidly resolved over 3 days, lea…
18y · Male·Incised wound to right axilla with complete transection of basilic vein, brachia…
Thomas Redman, aged 18, sustained a catastrophic laceration to his right axilla involving complete transection of major arteries and veins after putting his arm through a glass window at a rural property near Gloucester,…
45y · Female·haemorrhage due to traumatic rupture of the liver
A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…
43y · Female·neck compression due to hanging
…pression with melancholic features, possible psychotic symptoms, and elevated self-harm risk. However, the acute crisis intervention service (EACIS) implemented community-based home visits instead, citing lack of availa…
32y · Male·Valproic Acid Overdose
… found these omissions 'inappropriately superficial and dismissive' and concluded they 'contributed to his death'.
55y · Male·Subdural haematoma in a man with diabetes mellitus and chronic kidney disease (r…
…ne next-of-kin recorded despite protocol requiring at least two. No clinical errors were identified in the acute management. Improvements recommended include proactive identification of suitable patients for the Termina…
53y · Male·multiple injuries sustained in a fall from the first floor
…other patient's behavioural needs, allowing Kelvin to access the roof where he fell. The coroner found the death preventable, noting that consistent 24-hour specialised supervision from admission would likely have saved…
41y · Male·Multiple traumatic injuries
This inquest examined the death of a 40-year-old man who died by suicide following a fall from a cliff. He had three involuntary admission…
15y · Female·Hanging
Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
19y · Female·multiple injuries sustained in a train incident
…admissions and was under care of St Vincent's Hospital Mental Health Service (SVHM) in the week before her death. Key issues identified: inadequate engagement with family despite their expressed concerns about escalatin…
18y · Female·Mixed drug toxicity
…disorder, died from mixed drug toxicity after intentionally overdosing on propranolol while admitted to an acute mental health unit under involuntary treatment. She had a documented history of medication stockpiling and…
14y · Male·Hanging
… care. Mental health services were inaccessible; a psychology appointment was scheduled for the day of his death. The coroner found systematic failures in recognizing CJ's mounting risk despite clear warning signs, inad…
40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…
Micky Craig Revera, a 40-year-old man with chronic heroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent poli…
33y · Male·hanging
Moses Kellie, aged 33, died by hanging at Villawood Immigration Detention Centre in January 2019 after four years in immigration detention. He had schizophrenia, PTSD, and substance dependence, with a prior suicide attem…
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