20y · Female·injury caused by hanging
A 20-year-old woman with a long history of eating disorder, obsessive-compulsive behaviours, and adjustment difficulties died by suicide in October 2009. Sh…
28y · Female·aspiration of gastric contents complicating laxative abuse
…ere laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a CT scan revealed dozens of tablets in her stomach, but staff accepted her expl…
70y · Female·bronchopneumonia
…a while an involuntary inpatient at an aged psychiatry unit. She had longstanding anxiety, depression, and eating disorder with recent significant physical and mental health deterioration. Pneumonia was diagnosed on 12 A…
15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa
…ions over two years with escalating food refusal, self-harm, and suicidal behaviour. Key clinical lessons: eating disorder services require integrated medical-psychiatric teams; brief admissions without ensuring sustaine…
Female·complications of anorexia nervosa
…k with NSW Health to improve access to and pathways for specialist inpatient beds for patients with severe eating disorders, highlighting a systemic gap in available specialist mental health inpatient care for this vulne…
56y · Male·Aspiration of food bolus
Jimmy Delcus, a 56-year-old man with autism, intellectual disability and schizoaffective disorder, died from aspiration of a food bolus while eating lunch in a park. He was receiving supported living ser…
18y · Female·Compression of the neck in circumstances of hanging
Stephanie Winberg, an 18-year-old female with a complex medical history including eating disorder, major depressive disorder, and post-traumatic stress disorder following a friend's death, died b…
54y · Female·unascertained
…leted before leave; (3) Knowledge of patient's prior absconding history should inform risk assessment; (4) Eating disorder services require multidisciplinary coordination from admission; (5) Family should be consulted fo…
21y · Female·Neck compression
Kira Shae James, a 21-year-old with psychosis, borderline personality disorder, and eating disorder, died by ligature at Thomas Embling Hospital while an involuntary inpatient under Me…
31y · Female·organ failure due to anorexia nervosa
…treatable; lack of coordinated transition from paediatric to adult services; absence of a robust statewide eating disorder service requiring her care to be fragmented across public, private, and primary care settings; an…
56y · Female·sepsis secondary to disseminated pancreatic adenocarcinoma
…intestinal symptoms (weight loss, nausea, vomiting, epigastric burning) initially attributed to relapse of eating disorder in context of life stress. Abnormal liver function tests in August 2019 prompted appropriate esca…
59y · Female·Hypoxic-ischaemic encephalopathy due to acute upper airway obstruction
…d 59, died from hypoxic-ischaemic encephalopathy due to acute upper airway obstruction by food bolus while eating dinner at her aged care facility. She was a resident at Clearview Manor, a locked care facility, under a g…
18y · Female·Mixed drug toxicity
Tiesha Marie Derbyshire, an 18-year-old with complex mental health conditions including eating disorder, PTSD, and borderline personality disorder, died from mixed drug toxicity after intentionally ove…
69y · Male·bronchopneumonia and hypoxic brain injury following aspiration of food (choking)
A 69-year-old male with bipolar affective disorder and suspected frontotemporal dementia, admitted involuntarily to a psychiatric hospital, choked on bread …
14y · Male·Brain infarction caused by hypoxia following self-inflicted hanging by rope liga…
…h a history of anorexia nervosa and bulimia who died by hanging in April 2022. He had been discharged from eating disorder treatment in November 2021 after maintaining appropriate weight. In the months before his death, …
31y · Male·Hypoxic ischaemic brain injury secondary to hanging
Craig Akerblom, a 31-year-old man with depression, anxiety, substance abuse, and selective eating disorder, died by hanging resulting in hypoxic-ischaemic brain injury. He had been under care of multiple …
Female·Fulminant hepatic failure due to paracetamol toxicity
A 19-year-old female with anorexia nervosa, borderline personality disorder, and chronic suicidality was admitted to St Vincent’s psychiatric inpatient unit on 28 July 2023. She rep…
15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…
HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastr…
76y · Male·Upper airway obstruction by food bolus in a man with ischaemic heart disease
…e had recently been diagnosed with ischaemic heart disease requiring bypass surgery and bipolar affective disorder, managed with depot antipsychotic medication under a Community Treatment Order. At a barbecue, he was obs…
51y · Female·Complications of anorexia nervosa
…opinion indicated she should have been involuntarily detained for stabilization and transfer to specialist eating disorders unit, or if discharged, required daily medical and nursing support. The hospital failed to recog…
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