30y · Male·head and chest injuries sustained in a fall from a height
…d found no basis for involuntary intervention. En route to hospital with his sister, he abruptly exhibited manic behaviour, absconded from the car, and subsequently jumped while acutely psychotic. The coroner found the …
49y · Male·Multiple injuries from a fall from height
…involuntarily to hospital in August 2012 for quetiapine overdose and alcohol intoxication, presenting with manic relapse. On the day of death, he was seen by his GP and mental health crisis team, both noting deteriorati…
43y · Male·aspiration of vegetable matter with occlusion of the upper airway
…ipolar disorder, died on 25 September 2001 from aspiration of vegetable matter while experiencing a severe manic episode. In the two weeks before his death, multiple warning signs of psychiatric deterioration were docum…
52y · Male·Unascertained
…mental health inpatient unit on 2 December 2015. He was admitted voluntarily for management of a suspected manic relapse, assessed at low risk initially, and allowed leave to go outside despite guideline recommendations…
40y · Male·Asphyxia caused by a seizure resulting from severe alcohol intoxication. Underly…
…ures occurred: (1) The Maryborough Mental Health Unit discharged him twice in late July 2003 despite clear manic symptoms and documented history, citing absence of 'objective evidence of psychosis' and attributing behav…
56y · Male·Probable cardiac arrhythmia
Stephen Russell Harris, a 56-year-old man with a long history of schizophrenia and schizoaffective disorder, died of probable cardiac arrhythmia while an involuntary patient at Spencer Clinic on 18 December 2014. He pres…
26y · Male·bronchopneumonia following severe head injury
Ian Leslie West, a 26-year-old man with bipolar affective disorder, died from bronchopneumonia following severe head injury sustained when he fell from a hospital balcony on 31 December 2002. He had been admitted to Long…
23y · Female·Arrhythmia of unknown aetiology
TV died on 1 November 2016 from arrhythmia of unknown aetiology whilst in MHICU at Prince of Wales Hospital. She was a 23-year-old with severe bipolar disorder, mild intellectual disability and borderline personality tra…
40y · Male·unascertained
…inpatient unit (Upton House) on 3 January 2012. He was admitted involuntarily on 30 December 2011 during a manic relapse triggered by medication non-compliance, synthetic cannabis use, and back pain requiring opioids an…
51y · Female·drowning
…lding, a 51-year-old transgender female with longstanding bipolar affective disorder and recent psychotic episodes, died by drowning on 13 October 2017 after taking an unmanned dinghy into Copper Alley Bay without a lif…
22y · Male·ligature compression of the neck (hanging)
… while subject to a Community Treatment Order (CTO) for Schizoaffective Disorder. He presented with first-episode psychosis in 2017 and repeatedly refused antipsychotic medication throughout his illness, requiring three…
49y · Male·Unascertained - cardiac arrhythmia with terminal aspiration in an overweight man…
…ient at Bentley Mental Health Services. He presented to Royal Perth Hospital ED on 15 July 2020 with acute manic psychosis requiring sedation with ketamine and zuclopenthixol acetate (Acuphase). After transfer to Bentle…
2y · Male·Asphyxiation due to neck and/or chest compression
…r-old boy died from asphyxiation due to chest and neck compression inflicted by his mother during an acute manic psychotic episode. The mother had been admitted to psychiatric care in December 2008 with psychosis and wa…
53y · Male·Burns to 75% of body surface area and severe lower airway inhalation injury
… been detained at Glenside Hospital on 10 April 2008 under the Mental Health Act for bipolar disorder with manic features, assessed as at moderate to extreme risk of absconding given his repeated history of leaving with…
55y · Male·Immersion (Drowning) arising by way of suicide
Peter Daniel Mahoney, a 55-year-old man with treatment-resistant bipolar affective disorder, died by drowning on 13 June 2003 after absconding from Joondalup Health Campus where he was detained as an involuntary patient …
41y · Male·asphyxia due to neck compression following ligature suspension (hanging)
DR was a 41-year-old man with bipolar disorder, severe alcohol dependence, and multiple psychosocial stressors including family violence, homelessness, and financial crisis. In October 2023, he presented with acute mania…
27y · Male·compression of the neck due to hanging
Theo Papageorgiou, a 27-year-old man with a history of psychotic and manic symptoms since November 2014, was briefly detained under a mental health order in November 2015 but discha…
49y · Male·incised injury to the neck
Andrew Key, a 49-year-old man with bipolar affective disorder, died by suicide on 11 August 2015 after self-inflicting a neck injury while being restrained by police. Clinical lessons emerged regarding mental health asse…
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