Coronial

167 results for acute mental health deterioration

NSWcommunity2026-02-05

Inquest into the deaths at Westfield Bondi Junction Volume 1

40y · Male·Victims: fatal stab wounds from knife attack; Joel Cauchi: fatal gunshot wounds …

…019, and provided inadequate discharge information when he left her care in March 2020. Cauchi was lost to mental health follow-up for over two and a half years and did not engage with services in NSW despite homelessnes…

psychiatrygeneral practicecommunicationsystemclozapine
WA2013-05-30

Inquest into the Death of Mcdonald, Charles Edward

38y · Male·Acute drug toxicity due to clozapine-induced cardiac arrhythmia

A 38-year-old remand prisoner with schizophrenia on clozapine died suddenly in prison from acute drug toxicity (clozapine-induced cardiac arrhythmia). He had been transferred from psychiatric hospital to…

psychiatrypharmacologycommunicationsystemclozapine
NSW2024-05-21

Inquest into the death of Mohamed Warwar

35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…

…cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues and drug-induced psychosis, prescribed amisulpride 200mg which was increased to 600mg on 20 …

psychiatrycardiologycommunicationdiagnosticamisulpride
VICmental health2013-06-18

Finding into death of Paul Allan Skinner

29y · Male·hanging

…unication between medical and nursing staff, absence of occupational therapy, and failure to remove environmental hazards. While individual clinical judgment was not faulted, serious systemic deficiencies represented los…

psychiatrycommunicationsystem
SA2010-11-19

Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within t…

…zures, medication non-compliance, 72-hour sleep deprivation); (2) inappropriate application of a community mental health management plan to a custodial setting, which recommended avoiding detention despite manifestations…

neurologypsychiatrydiagnosticcommunicationvigabatrin
SAhospital2024-05-16

Coroner's Finding: Fisher, Lynne Patricia

60y · Female·sepsis due to community acquired pneumonia

…r 2018 with bilateral community-acquired pneumonia and was discharged after 6.5 hours despite clinical deterioration. She collapsed at home within hours and died at Royal Adelaide Hospital. The coroner found her death w…

emergency medicinegeneral practicediagnosticdelayamoxicillin/clavulanate
NSW2021-03-11

Inquest into the death of Nathan REYNOLDS

36y · Male·bronchial asthma

…rt evidence confirmed that earlier ambulance dispatch could have given him a chance of survival. More fundamentally, during his four months in custody, Nathan's severe asthma was never properly assessed or managed; he wa…

respiratory medicineemergency medicinediagnosticsystemsalbutamol
189

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