192 results
49y · Male·Diabetes Mellitus and the Consequences thereof
Mr Edward Curic (49) died at Long Bay Correctional Complex on 21 May 2022 from diabetes mellitus and complications. He had poorly controlled Type 2 diabetes for 30 years with severe complications including bilateral ampu…
85y · Male·Aspiration pneumonia in the setting of ischaemic heart disease, type 2 diabetes …
An 85-year-old man died of aspiration pneumonia in a prison healthcare setting while receiving palliative care. He had experienced a stroke two years prior resulting in cognitive decline and required assistance with all …
66y · Male·metastatic adenocarcinoma (palliated) from an unidentified primary tumour
Bradley John Murdoch, a 66-year-old prisoner serving a life sentence for murder, died in the palliative care unit of Alice Springs Hospital from metastatic adenocarcinoma on 15 July 2025. He had presented to the correcti…
41y · Female·Mixed drug toxicity (alprazolam, clonazepam, diazepam, methadone, metoclopramide…
Catherine Lynch, a 41-year-old nurse, died from mixed drug toxicity in July 2022 in circumstances consistent with suicide. She was experiencing severe family violence, including coercive control, threats, stalking and em…
67y · Male·Congestive cardiac failure
Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and comple…
0y · Male·Complications following forceps delivery
A 3-day-old neonate died from complications of instrumental forceps delivery, specifically subgaleal haemorrhage with associated skull fracture and intracranial bleeding. Critical clinical lessons include: (1) complex fo…
57y · Female·aspiration of gastric contents caused by combined drug and alcohol toxicity resu…
A 57-year-old woman with complex medical and mental health conditions died from aspiration of gastric contents caused by combined drug and alcohol toxicity. She had severe chronic pain following abdominal surgeries, opio…
67y · Male·hypoxic respiratory failure in the setting of pneumonia, pulmonary embolism and …
Peter John Wallace, aged 67, died in custody at Lyell McEwin Hospital from hypoxic respiratory failure complicating pneumonia, pulmonary embolism, and advanced hepatocellular carcinoma. He had been imprisoned at Yatala L…
55y · Male·Complications of traumatic head injury sustained in a workplace incident (pallia…
David Klingberg, a 55-year-old experienced pile testing engineer, died from traumatic head injury sustained when an auxiliary line hook on a piling rig struck him in the face at a construction site. The hook became jamme…
88y · Female·Complications of cholecystectomy surgery
Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
27y · Male·effects of fire
Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic…
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm
Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…
61y · Male·Multiorgan failure, due to, or as a consequence of metastatic lung cancer (suspi…
Shane Anthony May, a 61-year-old prisoner, died of multiorgan failure secondary to metastatic lung cancer after 44 days in custody. He presented with COVID-19 symptoms on reception, then developed progressive respiratory…
2y · Male·Drowning
Master K, a two-year-old, drowned in a hotel pool after falling from a step into the deeper adult pool section. He remained unnoticed underwater for over nine minutes while his mother was distracted by her mobile phone, …
Unknown·Sodium nitrite toxicity
Two deaths from sodium nitrite toxicity: Laurence Cox (63) and his daughter Ryley Cox (32). Laurence had a history of depression, anxiety, chronic pain, and medical conditions including emphysema and legal blindness, and…
Sodium nitrite toxicity
A 63-year-old man with a history of depression, anxiety, and chronic medical conditions including emphysema and blindness, and his 32-year-old daughter with depression, anorexia, and substance abuse, died from sodium nit…
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