319 results
30y · Male·Acute pneumonia and multi-organ failure, due to or as a consequence of traumatic…
Faysal Ishak Ahmed, a 30-year-old Sudanese refugee, died from traumatic brain injury sustained in a fall down stairs at Manus Island Regional Processing Centre on 22 December 2016. He collapsed and fell while alone, like…
50y · Female·Cardiac hypertrophy in the setting of epilepsy
Louise Anne Turner, a 50-year-old woman with cerebral palsy, intellectual disability, schizophrenia, epilepsy and dysphagia, died from cardiac hypertrophy in the setting of epilepsy. She experienced falls and declining m…
53y · Male·Complications of hypoxic brain injury secondary to mixed drug toxicity (methylam…
BT, a 53-year-old man with substance use disorder and mental health conditions, died from complications of hypoxic brain injury secondary to mixed drug toxicity (methylamphetamine, benzodiazepines, metonitazene). He inje…
61y · Male·aspiration pneumonia in a man with Down syndrome and early onset dementia
Stephen Feltscheer, a 61-year-old man with Down syndrome and early onset dementia living in Specialist Disability Accommodation, died from aspiration pneumonia. He was admitted to hospital on 25 July 2024 with a two-day …
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
79y · Male·Complications of peripheral vascular disease with Type 2 Diabetes Mellitus, atri…
John Reginald Wright, a 79-year-old remand prisoner, died from complications of peripheral vascular disease with diabetes, atrial fibrillation, cardiomyopathy and delirium. He was transferred to Princess Alexandra Hospit…
62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…
John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…
0y · Male·Head injury sustained in a difficult delivery including head impaction and caesa…
Baby Sidney died from severe hypoxic-ischaemic encephalopathy caused by head impaction during a difficult vaginal delivery attempt and subsequent caesarean section at 6 days old. The coroner found that medical care fell …
83y · Male·end-stage Parkinson's disease (palliated)
Raymond John Blackney, an 83-year-old man with end-stage Parkinson's disease, died in custody at Port Phillip Prison from natural causes. He had complex medical needs including dementia, intellectual disability, and mult…
57y · Male·Metastatic lung adenocarcinoma (stage IVA non-small cell lung cancer)
Trevor Charles Stone, a 57-year-old First Nations man imprisoned for sexual offences, died from metastatic lung adenocarcinoma with contributing comorbidities (diabetes, hypertension, dyslipidaemia, ischaemic heart disea…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
44y · Male·Complications following seizure on a background of acquired epilepsy; acquired b…
Anthony Dzaja, aged 44, died from complications of seizures secondary to acquired brain injury sustained in a 1997 motor vehicle accident. He had progressively deteriorated over several years with worsening epilepsy, cog…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
35y · Male·Neck compression due to hanging
Joshua Gonzalez, 35, died by suicide on 5 September 2020 after being discharged from Footscray Hospital. He had been apprehended by police under section 351 of the Mental Health Act after threatening self-harm and asking…
23y · Male·Multiple injuries from being struck by train
Jalen Hunter Norris, aged 23, died by suicide when struck by a train on 9 April 2021. He was experiencing paranoid delusions and had recently been arrested for criminal damage and cannabis possession after an incident at…
55y · Female·Multiple injuries sustained in a train incident
Andrea Milner, a 55-year-old woman with cerebral palsy, depression, and anxiety, died from multiple injuries sustained when she drove her motorised wheelchair off a railway platform onto tracks at Ormond station on 23 Se…
74y · Female·Infective exacerbation of chronic obstructive airways disease in the setting of …
Caroline McCormack, 74, died from infective exacerbation of chronic obstructive airways disease following a medication administration error where pregabalin was erroneously included in her Webster-pak despite being cease…
68y · Female·Terminal palliation in the setting of ischaemic liver and bronchopneumonia
Ms Heather Ash, a 68-year-old woman with intellectual disability, Parkinson's disease, and dementia living in supported disability accommodation, died from terminal palliation in the setting of ischaemic liver and bronch…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
21y · Male·Complications of injuries sustained when a trench wall collapsed
Jack Brownlee, 21, died from crush injuries sustained in a workplace trench collapse at a construction site. Despite family concerns that excavator use during rescue exacerbated his injuries, expert geotechnical and resc…
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