348 results
50y · Female·Intracranial haemorrhage (left frontoparietal intraparenchymal haemorrhage with …
Janene Louise Weston, a 50-year-old woman with acquired brain injury from autoimmune encephalitis and history of multiple strokes, died at home in specialist disability accommodation from an intracranial haemorrhage. She…
94y · Female·Drug toxicity (baclofen, gabapentin, oxycodone, pregabalin, zolpidem)
A 94-year-old residential aged-care resident died from drug toxicity after receiving another resident's medications. An agency nurse, unfamiliar with the patient and interrupted during medication preparation, failed to p…
72y · Male·Complications of suspected upper gastrointestinal tract haemorrhage, hospital ac…
A 72-year-old man with metastatic squamous cell lung cancer and multiple serious comorbidities was admitted to Ballarat Hospital in July 2024 with lethargy, fatigue, and rapid atrial fibrillation. Due to medication chart…
57y · Male·Metastatic lung adenocarcinoma
Wen Liang Zhang was a 57-year-old remand prisoner diagnosed with metastatic lung adenocarcinoma shortly after arrest on 26 September 2025. He declined chemotherapy and radiotherapy, choosing palliative pain management in…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
72y · Female·Combined drug toxicity (tapentadol, fluoxetine)
Linda Joy Bridle, 72, died from combined drug toxicity (tapentadol and fluoxetine) with a contributing subdural haemorrhage. She had multiple chronic conditions including heart failure and chronic pain, managed through c…
51y · Male·Complications of stage 4 hepatocellular carcinoma
Phillip Graeme Abell, aged 51, died from stage 4 hepatocellular carcinoma (HCC) with underlying cirrhosis and hepatitis C infection. Imprisoned at Woodford Correctional Centre, Mr Abell was diagnosed with infiltrative HC…
83y · Male·Metastatic melanoma
Maxwell John Beever, aged 83, died from metastatic melanoma on 8 July 2022 while in custody at Robina Hospital. A suspicious skin lesion was documented on 26 February 2021 but not investigated until 26 June 2021, delayin…
34y · Male·multiple gunshot wounds
SK, age 34, died on 10 January 2024 after being shot 12 times by NSW Police tactical officers at a medical practice in Nowra. He had chronic schizophrenia, opioid dependence, and was experiencing active psychosis. His GP…
25y · Female·Mixed drug consumption (pregabalin, oxycodone, desmethylvenlafaxine, aripiprazol…
Kaylah Veronica Sarah Woollard, age 25, died from mixed drug toxicity in the context of significant natural disease. She had WHO Class III obesity (BMI 94.5), cardiac hypertrophy, and mental health conditions (depression…
37y · Female·sepsis secondary to rectosigmoid perforation on a background of metastatic squam…
Carmen Jayne Clancy, aged 37, died on 27 September 2022 from sepsis secondary to rectosigmoid perforation caused by metastatic cervical cancer. Incarcerated on home detention following a cancer diagnosis in 2021, she und…
82y · Male·Multiorgan failure due to neurological failure due to Parkinson's disease with a…
Mr M, aged 82, with advanced Parkinson's disease and dementia, developed severe pressure injuries while in residential aged care. A significant sacral pressure wound went undetected until mid-December 2023 and rapidly de…
42y · Male·Gunshot injury to the head
AT was a 42-year-old secondary school teacher with diagnosed depression, adjustment disorder, and ketamine abuse beginning in 2019. He received inpatient psychiatric treatment in August 2021. On 20 December 2024, followi…
Unknown·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …
18y · Male·mixed drug toxicity due to oxycodone, alprazolam, alcohol and cocaine
Clem McCullough, 18 years old, died of mixed drug toxicity on 8-10 June 2019 after consuming oxycodone, alprazolam, alcohol and cocaine. He was found deceased in his car at Terrigal, NSW. The inquest revealed suspicious …
44y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest in the setting of p…
Elizabeth Ferris, a 44-year-old woman with schizoaffective disorder and polysubstance use disorder, died from hypoxic ischaemic encephalopathy following cardiac arrest in the setting of presumed drug toxicity. She was fo…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
An 87-year-old woman with Parkinson's disease sustained an unwitnessed fall at a residential aged care facility, resulting in head injuries and a hip fracture. Critical clinical lessons emerged: (1) neurological observat…
40y · Male·Gunshot wound to neck
Benjamin Freear, aged 40, died from a gunshot wound to the neck sustained during a police siege on 8 December 2019 in rural Queensland. He had been diagnosed with ADHD in April 2018 and prescribed dexamphetamine by psych…
53y · Male·Aspiration pneumonia in the setting of Down syndrome and pelvic fractures
Damien Mark Stone, a 53-year-old man with Down syndrome and early-onset Alzheimer's disease, died from aspiration pneumonia following a pelvic fracture sustained during hospital admission. Key clinical lessons include: (…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.