39 results
78y · Male·Acute pancreatitis
A 78-year-old man with a long history of mental illness and multiple chronic physical conditions died from acute pancreatitis on 12 May 2025, nine days after presenting with nausea and vomiting at Thomas Embling Hospital…
64y · Male·Aspiration event obstruction in a man with oropharyngeal dysphagia and Parkinson…
Richard Ellis, a 64-year-old man with intellectual disability, schizophrenia, Parkinson's disease and oropharyngeal dysphagia, died from aspiration obstruction following a witnessed choking episode while eating. He prese…
54y · Female·choking on a food bolus in a woman with an intellectual disability and other med…
Tracie Lyndal Markwick, a 54-year-old woman with intellectual disability and dysphagia, died from choking on food at her day placement centre. She had a documented mealtime management plan indicating mild-to-moderate cho…
66y · Male·Complications of excess alcohol intake in a man with heart disease
A 66-year-old man died from complications of excess alcohol intake in the setting of underlying heart disease. He had a 40+ year history of heavy daily alcohol consumption (12+ cans of beer plus whiskey daily), chronic p…
81y · Female·Multisystem failure in the setting of hyponatraemia secondary to chronic malnutr…
An 81-year-old woman with chronic schizophrenia, heart failure, and dementia died from multisystem failure secondary to severe malnutrition and hyponatraemia. Over four years, her son (Medical Power of Attorney) progress…
31y · Male·undetermined
Erol Elmas, a 31-year-old man with schizoaffective disorder, died in custody at Thomas Embling Hospital on 30 November 2022. The cause of death remains undetermined despite thorough pathological investigation. Mr Elmas w…
35y · Male·cardiac arrhythmia with amisulpride toxicity, and myocarditis being contributory…
35-year-old Mohamed Warwar died in custody at Metropolitan Remand & Reception Centre from cardiac arrhythmia with amisulpride toxicity and myocarditis. He was admitted to custody with a history of mental health issues an…
28y · Female·Effects of fire
Ya Zhao, 28, died from effects of fire in her residential unit on 22 July 2022. She had schizophrenia with a history of mental health crises, depression, self-harm and suicidal ideation. She was living independently with…
62y · Male·cardiac arrest complicating psychotic episode
Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…
37y · Male·Plastic bag asphyxia
Michael Delaney, a 37-year-old man with treatment-resistant schizophrenia, died by plastic bag asphyxia while residing at supported independent living accommodation. He had multiple suicide attempts and was under the car…
43y · Female·Complications of morbid obesity, including progressive respiratory and cardiac f…
Nicole Abbott, 43, died from complications of morbid obesity (BMI 54.4) including progressive respiratory and cardiac failure, exacerbated by smoking and obstructive sleep apnoea. She was subject to a Psychiatric Treatme…
36y · Male·Bronchopneumonia in a man with epilepsy
Jonathan Palmer, a 36-year-old man with epilepsy and intellectual disability living in a group home, died from bronchopneumonia on 24 February 2018. On 23 February, he developed respiratory symptoms (coughing, runny nose…
54y · Female·hypothermia, likely related to drug toxicity
Sandra Anne Brown, a 54-year-old woman with multiple chronic conditions including COPD, diabetes, bipolar disorder and epilepsy, died from hypothermia likely related to drug toxicity. She presented to the ED with breathi…
47y · Male·mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam and diazepam)
Matthew Clayton Lyons, a 47-year-old man with longstanding schizophrenia, severe anxiety, and substance abuse history, died from mixed prescription drug toxicity (quetiapine, olanzapam, lorazepam, diazepam). He had expre…
61y · Male·Undetermined
Gerard Guy Vaz, a 61-year-old man with bipolar disorder, obstructive sleep apnoea, and renal impairment, was admitted to Maroondah Hospital on 2 April 2015 with acute manic relapse with psychosis. He was administered zuc…
51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)
A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …
24y · Male·Massive blood loss caused by incised wounds of left upper extremity
A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, …
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…
37y · Male·cardiac arrhythmia
A 37-year-old man died in custody from cardiac arrhythmia, with morbid obesity and concurrent psychotropic medications carrying QT-prolongation risk identified as contributing factors. Key clinical lessons include: (1) p…
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