73 results for “mental state examination”
45y · Female·haemorrhage due to traumatic rupture of the liver
…r cutting her wrist deeply with a carving knife. The treating casualty officer did not properly document a mental state examination, failed to detect signs of active psychosis (auditory hallucinations), and did not detai…
33y · Male·Mixed drug toxicity
…had not shown improvement in withdrawn behaviour. Critical omissions included: no documented comprehensive mental state examination specific to the leave decision, no contact with family members despite valid consent to …
34y · Female·Hanging with combined effects of ethanol and benzodiazepines
…al and assessed by psychiatric nurse Gary Cox about 4 hours after arrival. Mr Cox did not conduct a formal mental state examination or risk assessment despite knowing of her recent attempted hanging, focusing instead on …
22y · Male·Multiple injuries secondary to fall from a height
…patient unit at Orygen Youth Health on 19 January 2011. Critical clinical shortcomings were identified: no mental state assessment or meaningful engagement documented over 10 hours (9:45pm to 8:29am) despite nursing care…
47y · Male·neck compression due to hanging
…D doctor dismissed a triage note of suicidality without psychiatric consultation, documenting insufficient mental state examination details. EACIS workers failed to fully explore documented warning signs including a noos…
20y · Male·Unascertained - cause of death could not be determined due to advanced decomposi…
…hts challenges in missing person investigations involving substance use, the limitations of post-mortem examination after prolonged water immersion, and the importance of emergency call systems functioning effectively t…
36y · Male·Unknown; presumed unsurvivable injuries or drowning following intentional cliff …
…ozapine reasonable but noted the reduction rate could have been slower. Key clinical lesson: comprehensive mental state documentation during antipsychotic withdrawal and maintenance of shared care models (including regul…
86y · Male·pulmonary embolism following deep vein thrombosis
…le admitted to the psychiatric unit at Launceston General Hospital on 26 May 2020. He was admitted under a Mental Health Act assessment order following a relapse of psychotic depression at his aged care facility. Clinica…
45y · Male·bronchopneumonia and suppurative bronchitis complicating hypoxic brain damage
… Multiple system failures contributed to his death: he was admitted to prison late at night without proper mental health screening despite clear documentation of depression and suicidality risk; nursing staff failed to c…
34y · Male·Long drop hanging resulting in complete decapitation
Jason Jenkins, aged 34, died by suicide (long drop hanging resulting in complete decapitation) on 17 June 2006, approximately 6 weeks after discharge from psychiatric admission on a Community Treatment Order. He had a 15…
52y · Female·Hanging due to depression
…ent depression, suicidal ideation, and borderline personality traits, was admitted to Cairns Base Hospital Mental Health Unit on 11 March 2008 with escalating suicidal ideation and plans to hang herself. On 14 March, aft…
47y · Female·unascertained
… partner Alan Smith. Despite immediate police notification and an intensive 12-day search involving NSWPF, State Emergency Services, RFS, and volunteers, Esther was not located alive. Her remains were discovered on 9 De…
27y · Female·hanging
…ob loss, with two recent suicide attempts including hanging. Clinical failures included: inadequate environmental safety (patient retained a three-metre scarf capable of use as a ligature despite admission for suicidalit…
54y · Male·hanging
…ion with electronic monitoring on 21 July 2020. His Community Corrections officer appropriately encouraged mental health support, and Mr Doran attended general practitioners who found no evidence of mental health issues …
41y · Male·haemorrhage due to incised wounds to left and right cubital fossae
… medical assessment by Dr K. was inadequate. The assessment lasted only 7-10 minutes for both physical and mental health evaluation, without documentation of depressive symptoms, assessment of stressors, or follow-up pla…
46y · Female·pulmonary thromboembolism due to bilateral deep calf vein thrombosis
…e psychotic illness. Staff recognised DVT risks and encouraged mobilisation, but comprehensive physical examination was hindered by her resistance. Elevated temperature and tachycardia on day 2-3 of admission were not v…
7y · Female·Multiple stab wounds to the back
…ident. Katica had been diagnosed with First Episode Psychosis in November 2020 and treated by NorthWestern Mental Health (NWMH). The coroner identified significant deficiencies in her mental health care: inadequate frequ…
34y · Male·Neck compression due to hanging
…abuse, high alcohol intake, and a recent suicide attempt died by hanging six weeks after being admitted to mental health services. Critical clinical lessons: (1) dual diagnosis (addiction and mental health) was not adequ…
53y · Male·unknown - no postmortem examination possible
…25 January 2017. He had experienced a domestic violence incident on 6 January 2017, was detained under the Mental Health Act but assessed as not at immediate risk of self-harm, and subsequently left home with minimal bel…
32y · Male·Self-inflicted gunshot wound to head
…k-driving offences, particularly those with significantly elevated BAC readings and evidence of underlying mental health concerns (depression, low self-esteem, emotional turmoil), should be routinely and substantially we…
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