54y · Male·Hypoxic-ischaemic brain injury attributed to cardiac arrest due to choking
…ld man with paranoid schizophrenia died of hypoxic-ischaemic brain injury from choking on food whilst in seclusion in a psychiatric intensive care unit. Key failures included: unsupervised provision of food to a patient…
31y · Male·undetermined
…22. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas was in seclusion following acute psychotic relapse and violent behaviour. Critical clinical lessons include: (1) vital si…
28y · Male·Hanging
Daylon Roeton, 28, died by hanging in a mental health seclusion room using a ligature made from blanket binding. He was admitted involuntarily after expressing suicidal…
21y · Male·unascertained
…nd extremely challenging violent behaviours, died at Joondalup Health Campus on 9 November 2022 while in seclusion under an involuntary treatment order. Despite extensive post-mortem examination, the cause of death rema…
Female·traumatic and hypoxic brain injury caused by numerous falls and self-beating of …
Miriam Merten died from traumatic and hypoxic brain injury sustained during 25+ falls while in seclusion in a mental health unit. Critical clinical failures occurred: she was not provided one-to-one observatio…
27y · Male·ligature strangulation
…relapse. The co-patient, classified as extremely high-risk for interpersonal violence, was released from seclusion after only three days despite documented difficulty assessing his mental state, marked demeanour changes…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
…ested a caustic substance causing severe oesophageal burns. During her distress, she was placed alone in seclusion without proper observation, then subjected to a 23-minute prone restraint with multiple safety breaches …
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
… diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabalin toxicity) whilst in seclusion in a mental health unit. Critical clinical failures included: inappropriate transfer from ICU to a menta…
39y · Male·respiratory failure and cardiac arrest
…lth ward where acute medical support was unavailable. During admission processes there, he was placed in seclusion after approaching the nursing station seeking cigarettes. Physical restraint to place him in security li…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
…ns. Critical failures included: (1) prolonged inappropriate stay in ED (62 hours) due to bed block, with seclusion occurring without proper documentation; (2) failure to conduct required respiratory checks during night …
26y · Male·neck compression due to hanging
…t order. Key clinical failures included: inadequate psychiatric documentation of previous rope-making in seclusion with expressed suicidal intent; failure to record the patient voluntarily surrendering items (jeans) to …
23y · Male·Hanging
…s admitted under the Mental Health Act following assessment for acute psychosis and had spent 39 days in seclusion across April and May. A key contributing factor was access to an unsupervised disabled bathroom containi…
79y · Male·Acute Myocardial Infarction; Underlying multiple pathologies including vascular …
…gement of agitation and cognitive decline related to vascular dementia. That evening, he was placed in a seclusion room with door open (therapeutic placement rather than formal seclusion) and given olanzapine orally. He…
22y · Male·Multiple injuries caused when the vehicle he was driving collided with a tree
…; (5) difficult ED management of acutely agitated, drug-affected psychotic patient, though coroner found seclusion in Purple Room appropriate. Clinicians used sound judgment under difficult circumstances. Key lessons: f…
43y · Male·Hanging
Mathew James Luttrell, a 43-year-old Aboriginal man with borderline personality disorder, chronic suicidal ideation and substance abuse, was admitted to Mildura Base Hospital following a suicide attempt on 11 November 20…
46y · Male·cardiac arrhythmia in a man with coronary arteriosclerosis and myocarditis
…uring his final admission, he became extremely agitated due to inability to smoke, required sedation and seclusion, then died overnight while sleeping. Two ECGs performed during admission appeared normal and did not det…
30y · Male·Acute Cardiac Dysrhythmia of Uncertain Aetiology
Giovanni Mario Franco, a 30-year-old man with schizophrenia, died on 10 March 1998 at Graylands Hospital from acute cardiac dysrhythmia of uncertain aetiology. During his final admission in February 1998, he developed se…
51y · Male·unascertained
Nigel Delaney, aged 51, died of unascertained cause while admitted to an acute psychiatry inpatient unit following relapse of schizoaffective disorder. He was found unresponsive during night observations and could not be…
35y · Female·neck and chest injuries and drowning due to intentional fall/jump from Tasman Br…
Jana Culic, aged 35, died by suicide jumping from the Tasman Bridge on 4 June 2020 while subject to a Mental Health Act treatment order for schizophrenia, borderline personality disorder, and bipolar disorder. She had a …
28y · Male·hypoxic brain injury sustained during restraint in the foyer of the Acute Mental…
Lyji Vaggs, a 28-year-old Aboriginal man with schizophrenia, died from hypoxic brain injury sustained during restraint at Townsville Hospital's Acute Mental Health Unit on 13 April 2010. He had declined admission at ED o…
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