181 results for “poor medication compliance”
59y · Male·Multiple injuries
Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
36y · Female·Effects of fire and stab wounds (for Matthew Maher); effects of fire (for Kylie …
Kylie Fowler, a 36-year-old woman with a 18-year history of schizophrenia requiring five involuntary psychiatric admissions, killed herself and her three children (Melanie, 13; Matthew, 11; Samantha, 18) on 9 January 201…
24y · Female·hypoxic brain damage due to cardiac arrest due to hanging
…dequate observation protocols (2-hourly rather than more frequent), insufficient psychiatric resources, and poor retention of experienced psychologists. The coroner found that while resuscitation was adequate, the death …
31y · Male·Self-inflicted hanging
…sues were identified: previous high-risk assessments from 1998–1999 were not available to 2004 staff due to poor record management; mental health services were severely under-resourced with only one psychiatric session w…
16y · Male·mixed drug toxicity (codeine, morphine, tramadol, alprazolam and desmethylvenlaf…
…rescription monitoring) was not yet available, the general practitioners who prescribed Schedule 4 and 8 medications to LI on a one-off basis missed critical opportunities to intervene by checking available resources lik…
78y · Female·Complications arising from a left femur fracture following an unwitnessed fall i…
Doreen Mansfield, a 78-year-old woman with bipolar affective disorder managed with lithium and ECT, was admitted to the Royal Hobart Hospital under a Mental Health Act treatment order. She sustained an unwitnessed fall i…
39y · Male·Infective endocarditis, with intravenous drug use as a contributing factor
Marc Vella, a 39-year-old man with schizophrenia and intravenous drug use, presented to St Vincent's Hospital with respiratory symptoms and chest pain. Clinical assessment identified pneumonia, septicaemia, and possible …
75y · Male·multifactorial causes on a background of ischaemic heart disease, generalised va…
…gh-risk profile; failure to recognise critically low urine output (3ml) post-operatively despite protocols; poor fluid balance charting and medication management (diuretics and anti-hypertensives continued inappropriatel…
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory dis…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…
42y · Male·hanging, an action taken by himself with the intention of ending his life
…ged from a psychiatric facility to an isolated rural island where his partner and children had left. He had poor insight into his mental illness, denied suicidal ideation throughout admission, and had low suicide risk sc…
15y · Male·Combined heroin and methamphetamine toxicity
… not receive consistent, sustained specialist care due to differing views about service eligibility and his poor engagement. Key clinical lessons include: the critical importance of placement stability for vulnerable you…
25y · Male·hypoxic-ischaemic brain injury due to plastic bag asphyxia
…ecisions should be documented. The treating team appropriately assessed suicide risk through monitoring, medication, involuntary treatment order, and frequent observations. This death highlights the importance of robust …
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
Male·Gunshot wounds to the head
… full knowledge of prior suicidal behaviour. After Noah's boating injury (September 2022), Wayne stopped medications. His mental health deteriorated by May 2023; Dr C. restarted treatment but couldn't escalate to acute s…
24y · Female·Ligature compression injury to the neck (hanging)
Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantle Hospital's Alma Stree…
1y · Male·Complication of burns and trauma to the mesenteric artery
A 15-month-old child died from complications of severe scalding burns (55% of body) sustained when left unsupervised in a bath of hot water (65°C) for 10-15 minutes, combined with traumatic mesenteric artery tears of unk…
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.…
13y · Female·Acute paracetamol toxicity
…g, distressed by family relationships, peer conflicts, and a relationship breakdown, all while experiencing poor school engagement and self-harming. Red Cliffs Secondary College staff responded appropriately to specific …
31y · Male·hanging (self-inflicted)
…The coroner found multiple contributing failures: inadequate mental health screening for suicidal ideation, poor communication between health and corrections staff, insufficient camera surveillance of the area where he h…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.