29 results for “undiagnosed mental health issues”
21y · Male·hanging
21-year-old Pacific Islander male died by hanging at home after relationship breakdown. He had undiagnosed depression, was using methamphetamine, and had a history of domestic violence perpetration with a prote…
23y · Male·Asphyxia from helium and plastic bag over head
…ational student from India, died by asphyxia from helium inhalation via plastic bag. He had experienced undiagnosed depression characterized by social withdrawal, disengagement from studies, and financial stress, but ne…
25y · Male·Gunshot injury to the head (Lachlan); gunshot injuries to head and chest (Terry)
…ers acted appropriately and professionally. Post-mortem psychiatric assessment found Lachlan likely had undiagnosed autism spectrum disorder and was experiencing severe depression and anxiety with suicidal ideation. No …
54y · Male·Ligature compression of the neck (hanging)
…t during welfare checks (neighbours were not spoken to in first two visits), critical risk information (undiagnosed mental health concerns) was not effectively transmitted to frontline officers, and there were no standa…
83y · Male·respiratory failure due to chronic obstructive lung disease
…ction. He was appropriately managed with non-invasive ventilation, antibiotics, and antipsychotics under a Mental Health Act order. Despite treatment, his condition deteriorated due to advanced airway disease unresponsiv…
24y · Male·Multiple injuries
…015 and experienced significant stressors including language barriers, academic difficulties, relationship issues, and insomnia. His sister observed depression and suicidal ideation but he refused professional help. The …
Unknown·Sally-Anne Wills: multiple stab wounds to the chest; Christopher Polden: single …
…him died from gunshot wounds inflicted by police during his apprehension. The coroner found no preventable issues with the police response. However, the finding notes that Mohammed may have been suffering from an undiagn…
40y · Male·Cardiomyopathy with early pneumonia in a man with reported sleep apnoea and high…
…ardiomyopathy with early pneumonia and obstructive sleep apnoea. He was readmitted to Graylands Hospital's mental health ward on 20 November 2014 with acute psychiatric decompensation and received sedation (haloperidol a…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
…olar 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 mental health ward …
66y · Male·Complications of excess alcohol intake in a man with heart disease
…umption (12+ cans of beer plus whiskey daily), chronic pain from previous bowel surgery and hernia, and undiagnosed mild heart disease. Post-mortem toxicology showed ethanol 0.16 g/100mL and evidence of alcoholic ketoac…
36y · Male·Hypoxic/ischaemic encephalopathy and hanging
…career. In the preceding days, he displayed severe mood swings, aggressive behaviour, and anger management issues related to amphetamine and cannabis use. He explicitly stated suicidal intent to multiple contacts. Clinic…
37y · Male·asphyxia due to oxygen deprivation secondary to inhalation of helium
…y clinical lessons: (1) Military veterans with untreated PTSD and relationship breakdown require proactive mental health assessment and support, even when they deny issues; (2) The escalating national problem of helium-a…
32y · Male·Gunshot wound to the head (Benjamin Green: homicide by William Markee; William M…
…abel, NSW. Markee shot Green in his sleep, then shot himself. Clinical lesson: Markee had clear, untreated mental health issues characterised by paranoid delusions, obsessive fixation, and suicidal ideation, but never en…
29y · Male
…st seen on 3 July 2013 in Canberra after purchasing a bus ticket to Sydney. He was grappling with personal issues including alcohol use, mental health concerns, and existential questions about life, religion, and spiritu…
31y · Male·ligature compression of the neck (hanging)
Stephen Sherwood, a 31-year-old Aboriginal man with untreated mental health issues and history of methylamphetamine use, died by suicide on 13 April 2022. He had attempted sui…
30y · Male·Benjamin Mark Aherne: gunshot wound to the head. John William Clements: suicide …
…ted), and the value of firearms registration and precautionary removal systems. This case demonstrates how mental health distress, even without prior psychiatric history, can lead to catastrophic violence when combined w…
36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…
A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive…
37y · Female·open finding - undetermined
…2013 hospitalisation during which she expressed suicidal ideation. Post-discharge, she received inadequate mental health follow-up with no ongoing therapy or strong therapeutic relationship established. She stopped psych…
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
…kg despite attempts at management. He received psychiatric care only 3 times over 8 months despite complex mental health needs. Critical gaps included no access to dietitian, Aboriginal Health Worker, or timely specialis…
52y · Female·gunshot wound to head
…text of decades of physical and emotional abuse by her husband, which was never reported to or detected by healthcare providers. Significant clinical lessons include: GPs should maintain a low threshold for asking about …
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