391 results for “psychiatric medication management”
68y · Male·Sudden Unexpected Death in Epilepsy (SUDEP)
…den Unexpected Death in Epilepsy (SUDEP). He had a 5-year history of seizures managed with antiepileptic medications, including a recent switch from valproate to levetiracetam (Keppra) in October 2019 due to inadequate s…
44y · Male·aspiration pneumonia
…iration pneumonia after a 15-day admission to Royal Adelaide Hospital. He was transferred from Glenside psychiatric hospital on 11 November 2002 with signs of chest infection and progressive physical deterioration. At R…
40y · Male·multiple injuries from fall from building
…d he deliberately jumped from the building with suicidal intent. He was compliant with his antipsychotic medication (clozapine, amisulpride, valproate) and showed no acute warning signs in the week before his death. The …
46y · Female·mixed drug toxicity
…t for suicide. The handover team discussed options but did not reach a clear decision about removing the medication or escalating care. The coroner found the death tragic but not preventable without substantially changin…
64y · Male·acute myocardial infarction in association with coronary artery atherosclerosis
…ay interference). He was admitted to the Mental Health Unit as an involuntary patient on 21 December for management of untreated schizophrenia and suspected vascular dementia, with plans to obtain guardianship orders to …
26y · Male·bronchopneumonia following severe head injury
…ony on 31 December 2002. He had been admitted to Longreach Hospital on 30 December 2002 for involuntary psychiatric assessment and awaiting transfer to Rockhampton Mental Health Unit. Despite receiving multiple sedative…
48y · Female·Head injury
… a Department of Health smoking prohibition policy forcing patients to leave the ward, and insufficient psychiatric continuity. The decision to allow unescorted leave was ultimately mistaken but not inherently wrong at …
59y · Female·Global hypoxic brain injury due to mixed drug toxicity, specifically alprazolam …
…ed by mixed drug toxicity, with alprazolam levels in the fatal range. She had intentionally taken excess medication on 28 September 2021 before receiving a COVID-19 vaccine dose, a pattern her daughter recognised as copi…
50y · Female·hanging
…ring and treatment were adequate, though she received only two psychiatrist reviews. Non-compliance with medication (65% rate across facility) and missed appointments (39% rate) were significant challenges. Clinicians no…
46y · Male·Consistent with exhaust fumes toxicity (suicide by carbon monoxide)
…ncreases suicide risk, particularly when multiple stressors accumulate; the importance of continuity of psychiatric care during employment transfers; and recognition that formal disciplinary processes (even for minor is…
Unknown·Erfinna Lay: Aspiration resulting from Acute Multiple Drug Toxicity; John Quirk:…
…er, and drug dependence. Coroner identified concerns about prescribing practices: inadequate controls on medication access despite multiple prior overdoses, reluctance to implement pharmacy-supervised dispensing or reduc…
33y · Male·Multiple injuries sustained from falling from height (fifth-floor window ledge) …
…s and immigration detention requires formal systems to ensure continuity of care—AB's ongoing Quetiapine medication was unknown at VIDC; (2) Mental health assessment conducted under restrictive security conditions (guard…
86y · Male·pulmonary embolism following deep vein thrombosis
Rex Rouse, 86, died from pulmonary embolism following deep vein thrombosis while admitted to the psychiatric unit at Launceston General Hospital on 26 May 2020. He was admitted under a Mental Health Act assessmen…
24y · Male·cardio-respiratory arrest due to multi-drug toxicity
… severe chronic arthritis, depression, polysubstance addiction and gambling disorder, died in a private psychiatric facility after admission for substance withdrawal management. Death resulted from cardio-respiratory ar…
37y · Male·stab wound to the chest penetrating the heart
…istory of command auditory hallucinations died by self-inflicted stab wound to the chest. Released from psychiatric hospital on 11 April 2011 on voluntary arrangements without a community treatment order despite previou…
Eva Arany: gunshot wound to the neck; Jeno Arany: traumatic brain damage complic…
An elderly man with severe depression, suicidal ideation, and ongoing psychiatric risk was hospitalised twice in 2000 and discharged on antidepressant medication. Despite staff identify…
44y · Male·mixed drug toxicity
Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and soma…
64y · Male·hypoxic encephalopathy, secondary to cardiac arrest, secondary to myocardial inf…
…ardial infarction and cardiac arrest while detained under mental health legislation. He refused all oral medications including cardiac and diabetes treatments. Despite chest pain and ECG changes consistent with ischaemia…
38y · Female·Unable to be determined
…fective disorder requiring intensive mental health support, depot antipsychotic injections, and multiple medications. Discharged from Canberra Hospital on 7 March 2014 with explicit recommendations for ongoing case manag…
15y · Male·multiple blunt force injuries as a result of being hit by a train
AB, a 15-year-old boy with depression and suicidal ideation, was prescribed Lexapro (escitalopram) by his GP despite it not being registered for use in adolescents. The coroner identified significant failures in clinical…
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