Coronial

14 results for acute mental status change

VICmental health2013-05-10

Finding into death of Michael Desmond McWhirter

79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular …

…ry (ischaemic heart disease, pulmonary fibrosis, pacemaker, renal impairment, vascular dementia) died from acute myocardial infarction while in acute psychiatric care. He was transferred to Peter James Centre from gener…

psychiatrygeriatric medicinecommunicationsystemolanzapine
TAShome2020-03-23

Coroner's Finding: Szemes, Kim Leonie Maree

59y · Female·Unable to determine - body too decomposed at autopsy

Mrs Szemes, a 59-year-old woman with longstanding mental health issues living alone, was found deceased after an interval of approximately 5 months. On 28 May 2018…

paramedicinepsychiatrycommunicationsystem
QLDprison2021-11-23

Row Row, Frederick Arthur James

34y · Male·Neck compression by hanging

…, a 34-year-old Aboriginal man, died by suicide in Capricornia Correctional Centre following a precipitous change in risk assessment from high to low in less than 48 hours. After assaulting another prisoner on 21 August …

psychiatrypsychologydiagnosticcommunication
VIChospital2009-12-22

Finding into death of Jodi Joy McPaul

33y · Female·Hypoxic brain injury secondary to plastic bag asphyxia

…s with quality-of-life considerations in chronic psychiatric illness, the need to recognize early signs of mental state deterioration (noted in final days), and enhanced environmental control measures. Toxicology showed …

psychiatryintensive careolanzapine
VIChome2010-03-15

Finding into death of Terence Thomas Wilson

76y · Male·Upper airway obstruction by food bolus in a man with ischaemic heart disease

…s. Autopsy confirmed triple vessel coronary atherosclerosis. The coroner found no relationship between his mental health supervision status and the cause of death. Clinical lessons include recognition of dysphagia risk i…

emergency medicinepsychiatrysodium valporate
WA2013

Inquest into the Death of Ms D

39y · Female·Septic shock and nosocomial pneumonia secondary to pentobarbital (Nembutal) over…

…ock and nosocomial pneumonia. She had been an inpatient at the Mother and Baby Unit (MBU) with involuntary status under the Mental Health Act 1996, then transitioned to voluntary status following a Mental Health Review B…

psychiatryintensive caresystemdelaypentobarbital
QLDmental health2013-07-02

Justin

35y · Male·Choking due to impaction of soap in airway

…ificantly impacts treatment and requires careful multidisciplinary review, particularly when psychiatrists change diagnosis; (3) rapid medication changes without adequate trial period and structured evaluation of alterna…

psychiatryintensive caresystemcommunicationrisperidone
VICmental health2012-01-31

Finding into death of John Bernard Tuffy

48y · Male·drowning

John Tuffy, 48, died by drowning after absconding from a mental health waiting room at Bayview House while awaiting transfer to hospital. He had returned from Ireland wit…

psychiatryemergency medicinecommunicationsystemtemazepam
VIChospital2012-03-02

Finding into death of Elsa Harrington

45y · Female·Multisystem organ failure secondary to acute liver failure associated with parac…

Elsa Harrington, a 45-year-old woman, died from acute liver failure secondary to paracetamol toxicity in November 2002. She was admitted post-hysterectomy with …

general surgerycardiologydiagnosticcommunicationparacetamol
NSWmental health2018-12-19

Inquest into the death of R R

38y · Female·neck compression (hanging)

RR, a 38-year-old woman with complex mental health history including PTSD, substance use disorder, and borderline personality traits, was admitted to …

psychiatryemergency medicinecommunicationsystem
QLDmental health2013-01-25

SH and AW

25y · Female·Chest injuries due to fall from height

…r-old male) died by suicide by jumping from the Buranda car park across from Princess Alexandra Hospital's Mental Health Unit within a 10-month period despite being involuntary patients on observation regimes with leave …

psychiatrydiagnosticcommunicationhaloperidol
VICcommunity2024-12-16

Finding into death of C L

53y · Male·Cervical spine distraction and hanging

…ious suicide attempt. He was assessed as high-risk but discharged after 19 days with referral to community mental health services. He died by suicide approximately 6 hours after discharge. The coroner found the general c…

psychiatryemergency medicinesystemdelaymirtazapine
VICmental health2013-06-18

Finding into death of Paul Allan Skinner

29y · Male·hanging

…ld with depression and recent suicide attempt, was admitted to a psychiatric inpatient unit on involuntary status. Despite being prescribed 15-minute observations by his treating psychiatrist, nursing staff implemented a…

psychiatrycommunicationsystem
VIC2012-09-21

Finding into death of Timothy Casey

41y · Male·Hanging

…le system failures: psychiatric assessment referrals were not acted upon despite evidence of deteriorating mental state and suicidal ideation; the downgrade of his suicide watch rating on 20 March was based on a non-clin…

psychiatrycorrectional healthdiagnosticcommunication

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