181 results for “poor medication compliance”
55y · Male·Septicaemia due to hydronephrosis and infection
… challenge patient refusals when safety is genuinely compromised, maintain engaged follow-up despite non-compliance, and flag patients with complex needs across service providers.
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
…ent would deny symptoms to others, and instead advised the parents to withdraw support—advice described as 'poor' by expert psychiatric testimony. The GP had prescribed benzodiazepines which may have disinhibited behavio…
57y · Male·streptococcus pneumonia septicaemia due to splenectomy
…ailures were identified: inadequate sepsis protocols, restricted access to infectious diseases specialists, poor escalation culture, and insufficient overnight medical staffing. The coroner made no individual criticisms …
41y · Female·unable to determine
…Hospital on 1-2 November 2017 with acute psychosis related to schizophrenia, having ceased antipsychotic medication and methadone. The mental health and emergency departments disagreed over her care—mental health would n…
22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree
…ht; (3) inadequate discharge planning—no community mental health worker contacted before leave granted; (4) poor documentation of leave conditions; (5) difficult ED management of acutely agitated, drug-affected psychotic…
27y · Male·Hanging
…e shifts (up to 14 hours), and minimal time off. Despite being psychiatrically stable and compliant with medication, Marcus developed significant workplace stress from December 2017 onwards, characterised by burnout, fat…
51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …
…inter-agency communication regarding custodial orders. Systemic confusion about discharge procedures and medication management also contributed to risk.
17y · Male·Hanging
17-year-old Joshua Klumper died by hanging following cannabis withdrawal and workplace stress. He had a complex mental health history with ASD diagnosis (lacking robust diagnostic support), multiple suicide attempts, and…
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
…7pm to 2:00am would likely have been life-saving. Key failures included inadequate communication protocols, poor knock-up system audio quality, failure of rovers to conduct proper cell checks, and systemic under-resourci…
36y · Male·Alcohol toxicity from consumption of Listerine mouthwash
Kevin Meagher, a 36-year-old man with schizoaffective disorder, cerebral palsy and intellectual disability, died from alcohol toxicity caused by consumption of a 1-litre bottle of Listerine mouthwash. He was an involunta…
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
…ice about the sword possession and staffing availability; premature and unnecessary entry into his bedroom; poor coordination among police officers with conflicting plans; and lack of specialist resources. The officer wh…
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
A 32-year-old man died from pulmonary embolism six days after emergency appendectomy for perforated appendicitis. VTE prophylaxis was appropriately prescribed. However, the clinical team failed to investigate persistent …
44y · Male·Complications of blunt head injuries sustained in a motor vehicle incident (cycl…
A 44-year-old psychiatric nurse died from complications of blunt head injuries sustained when struck by a cyclist while cycling. The driver, who caused the collision, had a documented psychiatric history including schizo…
32y · Female·Compression of the neck
… health services discharged NLU with incomplete risk assessment despite documented family violence history, poor medication compliance, psychotic symptoms, and substance abuse; (2) NLU's diagnosis remained unclear (alcoh…
28y · Male·Multiple injuries sustained in a motor vehicle collision (driver)
…ear history of bipolar affective disorder with comorbid substance abuse disorder, personality disorder, and poor impulse control. The coroner identified critical system failures: absence of long-term involuntary detentio…
Male·Little Brother: multi-organ dysfunction due to hypothermia with contributing con…
…mal decision-making process addressing homelessness despite its profound health impacts; service gaps in medication management, aftercare for alcohol withdrawal, and residential facilities for people with cognitive impai…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
… stabilisation on sublingual Suboxone. She was opioid-naïve or with very low tolerance, obese (BMI 54), had poorly controlled diabetes, and was prescribed quetiapine. Following injection on 22 November 2021, she experien…
Male·Suicide: hanging (Al-Akabi, Saunders); diving from balcony (Rauluni)
…associated with systemic failures in inter-agency communication, risk assessment, mental health protocol compliance, and duty of care by DIAC, Serco, and IHMS. Al-Akabi's death was deemed theoretically preventable. The c…
Unknown·Ruby: ligature compression of the neck (hanging); Carly: ligature compression of…
…was hit by a vehicle. Common failures included: inadequate individual management and risk management plans, poor discharge planning, failure to involve families and carers in decision-making, inadequate follow-up procedu…
28y · Male·Multiple injuries sustained when struck by a freight train
Jacob Taulelei, a 28-year-old man with long-standing depression, anxiety, and suicidal ideation, presented to St John of God Hospital on 5 February 2020 expressing intent to jump in front of a train. Despite being assess…
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