848 results
43y · Female·unknown
Rita Anderson, a 43-year-old Aboriginal woman with chronic alcohol-related organic brain damage, was admitted to Royal Darwin Hospital in March 2002 for stabilization and placement planning. Unable to safely live indepen…
38y · Female·neck compression due to hanging
Margaret Lindsay, 38, died by hanging in Adelaide Women's Prison on 23 May 2001 whilst remanded in custody. She had a complex history of psychiatric illness, drug and alcohol abuse, and multiple suicide attempts. Despite…
16y · Male·Gunshot wound to the head
A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 August 2001. He had been under psychiatric care for 10 months, p…
16y · Male·fresh water drowning
Jason Sammut-Smith, a 16-year-old boy, died by fresh water drowning on 1 December 2001. The coroner found extensive evidence of physical abuse inflicted over months, including numerous bruises, abrasions, and injuries co…
45y · Male·Natural causes - cardiac arrest, most likely secondary to severe tardive dyskine…
Mark Andrew Burnside, a 45-year-old man with intellectual disability and chronic mental illness, died of natural causes on 7 November 2001 at Royal Perth Hospital. He had been prescribed thioridazine (Mellaril) for appro…
45y · Male·Bullet wound to the head - self-inflicted
A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…
29y · Male·Hanging
Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…
36y · Male·Large calibre gunshot wound to the chest
A 36-year-old Aboriginal man died from a gunshot wound to the chest inflicted by police during a confrontation while attempting to enforce a restraining order. After the deceased fled from police, he attacked a police of…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
17y · Female·mixed drug toxicity
Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…
38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…
A 38-year-old woman with long-standing heroin and benzodiazepine dependence died from mixed drug toxicity following injection of heroin. Her GP had prescribed multiple benzodiazepines (diazepam, oxazepam, temazepam) and …
17y · Female·mixed drug toxicity
Nicole Davies, 17, died from mixed drug toxicity after rapid methadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet receiv…
47y · Male·neck compression due to hanging
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…
24y · Male·Aspiration of vomit associated with combined drug effect
Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…
34y · Female·incineration and inhalation of products of combustion from motorised wheelchair …
Sandra Lee Rothwell, aged 34, died from incineration and inhalation of combustion products when a fire started in her motorised wheelchair while she was at home. She had severe cerebral palsy and was completely dependent…
33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes
A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…
45y · Female·haemorrhage due to traumatic rupture of the liver
A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…
26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…
26-year-old Marcio Jose Lay Nheu died from a closed head injury with extradural haemorrhage caused by a blow to the head with a Maglite torch at Karama Shopping Centre. He was struck by Rodney Foster during an altercatio…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
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