161 results for “polysubstance use”
35y · Male·Fentanyl toxicity
…icularly overnight when staff failed to conduct required two-hourly checks. He had a history of substance abuse, drug-seeking behaviour, and multiple medications. While his GP appropriately prescribed Fentanyl after con…
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
…rectional officers failed to respond appropriately. The control room officer misheard both calls, failed to use the reverse knock-up system to clarify, and did not alert the night senior. The rovers attended but did not…
23y · Female·hypoxic ischemic encephalopathy and aspiration pneumonia as a result of hanging
…nt. She had a complex psychiatric history with schizophrenia and borderline personality disorder, substance use, and intellectual disability. Critical clinical lessons include: early access to comprehensive psychiatric …
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…
20y · Unknown·Traumatic brain damage complicating gunshot wound to the head
…er had paranoid schizophrenia with antisocial personality traits, poor medication compliance, amphetamine abuse, and morbid jealousy directed at Ms Dinsdale. Despite intensive mental health involvement, threats of viole…
25y · Male·Injuries sustained when struck by a train (suicide)
Damon Brenden Amiet, a 25-year-old with schizoaffective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serio…
41y · Male·complications in association with effects of fire, with terminal palliative care
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…
26y · Male·Multiple injuries sustained in a motor vehicle incident (driver)
… in the preceding months with concerning symptoms but was released without involuntary treatment orders because he didn't meet statutory criteria at the moment of assessment. The case highlights the risks of police purs…
36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…
A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for t…
49y · Male·Hanging
A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …
42y · Female·Hypoxic ischemic encephalopathy with antecedent cause being self-caused near mis…
…Court Liaison Officer; lack of psychiatric assessment before transport despite clear warning signs; and the use of an unsuitable transport vehicle without surveillance. The coroner found the cumulative effect of systemi…
26y · Male·Neck compression from hanging
… administration and lack of clear at-risk assessment framework were identified. No single clinician error caused the death, but systemic improvements in prisoner mental health resourcing and policy compliance were recom…
27y · Male·effects of fire
Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
25y · Male·Multiple organ failure due to acute paracetamol poisoning
…rrival. Systemic failures included poor prisoner access to opioid substitution therapy driving illicit drug use, ready availability of stockpiled paracetamol, and misunderstandings of transfer protocols.
26y · Male·ligature compression of the neck (hanging)
Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…
Unknown·Multiple causes: hanging (three cases); exposure in context of organic brain dam…
…ing (ages 19, 25, 27); one by exposure (age 35). Deaths were linked to petrol sniffing (chronic substance abuse causing severe neurological damage), mental health issues, and systemic service failures. Key clinical less…
25y · Female·Chest injuries due to fall from height
…ts; failure to assess deteriorating mental state; lack of structured behavioural programmes for substance abuse; inappropriate facility unsuitable for long-term rehabilitation; and inability to enforce leave restriction…
36y · Male·Mixed prescription drug toxicity (morphine, lignocaine, amiodarone and midazolam…
…zolam stolen from the workplace drug store. The coroner found that while Crump's intentional act directly caused his death, significant organisational deficiencies at Ambulance Tasmania substantially contributed to the …
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
…s increased dramatically in 2006 (100% increase), with deaths strongly correlated to alcohol and cannabis abuse. The primary cause of death across most cases was ligature compression of the neck (hanging). The inquest r…
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