25y · Male·Head injury sustained on impact with a train
Edward Timothy Peterson, aged 25, was involuntarily admitted to Maroondah Hospital's psychiatric unit on 11 February 2021 with first episode psychosis. Clinical care by psychiatrist Dr C. was appropriate: medications wer…
74y · Male·Hospital acquired pneumonia complicating chronic lung disease
…and then to a mental health unit where he was placed on a Mental Health Act order for untreated psychotic disorder. His physical health deteriorated; he was transferred back to Royal Melbourne Hospital on 3 October 2016 …
25y · Female·injuries sustained by jumping from the Tasman Bridge
A 25-year-old woman with longstanding borderline personality disorder, chronic suicidal ideation, and substance abuse died by jumping from the Tasman Bridge on 4 January 1996.…
19y · Male·Ruptured aorta post motor vehicle incident
…lvement in discharge planning despite family concerns; and no diagnosis despite persistent disturbance of thought/mood. Clinicians prioritised maintaining therapeutic alliance over rigorous risk assessment. The coroner …
60y · Male·burn wounds and the consequences thereof
CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with p…
43y · Male·Hanging
Brett Andrew Pollini, a 43-year-old fire station officer with bipolar affective disorder, died by suicide following a distressing telephone call with the Child Support Agency (CSA) regarding a s…
31y · Female·Pneumonia; combined drug toxicity (including marijuana), smoking, pathological o…
…escription medications, cannabis, and obesity. Despite being treated by numerous specialists, there was no formal case management or coordination of care. Key failures included: lack of communication between prescribers …
41y · Male·Hanging
Timothy Casey, a 41-year-old remand prisoner with a history of major depressive disorder and drug/alcohol dependence, died by hanging in Port Phillip Prison in March 2008. The coroner identified…
26y · Male·multiple injuries from fall from height
…ards. Key failures included: lack of therapeutic continuity, dismissive labelling of 'malingering' without formal assessment (creating a barrier to appropriate care), poor communication between services and with family, …
32y · Male·Head and neck trauma (train impact)
Travis Hartskeerl, a 32-year-old man with a complex history of schizophrenia, polysubstance abuse, and multiple serious suicide attempts, died by suicide on railway tracks on 16 December 2008. He had been discharged from…
18y · Male·methadone toxicity
Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …
5y · Male·Presumed drowning
…analysis of risk, failed to share information effectively, and did not escalate concerns appropriately. No formal missing persons report was made by police despite meeting the definition. Children were not named as prote…
0y · Female·Unascertainable
Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …
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