80y · Male·asphyxia due to choking on food
…a with 40+ year history and poor compliance off medications. Clinical deterioration was profound: 3-week religious fasting causing significant weight loss, unattended for 5+ years by GP, bladder distension (3750 ml urin…
42y · Male·Hanging (self-inflicted) while suffering from serious mental illness
…ecords were not reviewed despite his complex history. On 10 September he expressed suicidal ideation and religious delusions without adequate escalation to psychiatry. The coroner found this 'unforgiveable' and a 'serio…
Constable Arnold: single gunshot wound to the chest. Constable McCrow: gunshot w…
…om shared delusional disorder characterised by persecutory beliefs, anti-government views, and end-times religious ideology. Four constables attended what appeared to be a routine missing persons job with no intelligenc…
42y · Female·salt water drowning
Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…
42y · Male·Incised injury to the neck resulting in exsanguination and air embolism
Naser Vukovic, a 42-year-old prisoner with severe psychotic symptoms and dual P1/S3 risk ratings, died by self-inflicted neck laceration in Melbourne Assessment Prison on 8 June 2016. Despite two prior self-harm incident…
2y · Female·drowning
A 2-year-old child died by drowning at her home in September 2016. Her mother was suffering from acute psychosis and had stopped taking antipsychotic medication days before the death. Critical failures occurred: the chil…
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