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…
47y · Male·unascertained
Eric Donald Brandrick, a 47-year-old man with significant disability from a right thalamic intracerebral haemorrhage stroke in September 1988, was last confirmed alive on 31 December 1989 at Royal Perth Hospital Emergenc…
43y · Female·Subarachnoid haemorrhage due to a ruptured berry aneurysm
Trina McGrady, a 43-year-old Goomeroi woman, died from subarachnoid haemorrhage due to a ruptured berry aneurysm on 15 September 2020. She had been admitted to John Hunter Hospital following incidental discovery of two l…
51y · Female·Multiorgan failure in the setting of WHO Class III obesity, chronic excessive al…
A 51-year-old woman with WHO Class III obesity, chronic alcohol consumption, and anaemia died of multiorgan failure following admission with community-acquired pneumonia and respiratory failure. She presented with abdomi…
25y · Male·hanging
Logan Brown, a 25-year-old man on home detention bail, died by hanging. He had a complex psychiatric history including borderline personality disorder, polysubstance use disorder, and chronic suicidal ideation dating fro…
50y · Male·Mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine); cardiac hype…
A 50-year-old man with treatment-resistant schizoaffective disorder died from mixed alcohol and drug toxicity (clozapine, paracetamol, caffeine) combined with cardiac hypertrophy. He ceased his antipsychotic medication o…
0y · Male·Streptococcus pyogenes and parechovirus infection
An eight-month-old boy in state care died from Streptococcus pyogenes and parechovirus infection. He presented to hospital twice before death with fever and ear infection symptoms. On first presentation (2 September), he…
44y · Female·Cardiac arrest in the context of several contributory factors (physical exertion…
Selesa Tafaifa, a 44-year-old woman with Samoan heritage, died in custody at Townsville Women's Correctional Centre on 30 November 2021 during physical restraint by correctional officers, including application of a safet…
30y · Male·Multiple injuries sustained in a train impact (truck driver)
John Frank Stubbs, a 30-year-old truck driver, died when his low-loader truck became stuck on a railway level crossing with a 7.5% gradient and was struck by a train traveling at 32 km/h. The truck's low-slung trailer bo…
70y · Male·intracranial haemorrhage secondary to haemorrhagic transformation of ischaemic s…
A 70-year-old man with chronic small vessel cerebral ischaemia died from intracranial haemorrhage following haemorrhagic transformation of an ischaemic stroke while in prison custody. He presented with acute stroke sympt…
65y · Male·Ischaemic heart disease in a man with epilepsy
Richard Paul Atkins, a 65-year-old man with intellectual disability and epilepsy living in specialist disability accommodation, died from ischaemic heart disease. Post-mortem examination revealed moderate to severe tripl…
36y · Male·Heroin toxicity
A 36-year-old man with a history of homelessness and intravenous heroin use died from heroin toxicity after overdosing in a public toilet block. Emergency services were called promptly by a bystander who remained at the …
15y · Female·Paracetamol toxicity in the setting of Anorexia Nervosa
Olivia Evans, 15, died from paracetamol toxicity in the setting of anorexia nervosa after intentionally overdosing. She had 38 inpatient admissions over two years with escalating food refusal, self-harm, and suicidal beh…
66y · Male·Undetermined (natural causes)
A 66-year-old man with multiple chronic conditions including Parkinson's disease, spastic gait syndrome, cognitive impairment, atrial fibrillation, and swallowing difficulties died at his supported disability accommodati…
68y · Male·Unascertained
JNY, a 68-year-old man, died from unascertained causes between 1-4 September 2020. His wife, RBT, administered temazepam-laced biscuits causing unconsciousness, then wrapped and placed him in a non-operational freezer. R…
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…
69y · Male·Haemopericardium secondary to ischaemic heart disease
Brian Matthew McDonald, a 69-year-old man with autism, intellectual disability, and epilepsy living in specialist disability accommodation, died from haemopericardium secondary to ischaemic heart disease. He collapsed in…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
32y · Male·1(a) Aspiration of gastric contents; 1(b) Combined drug toxicity
A 32-year-old Eritrean refugee died on 22 August 2017 in a mental health unit from aspiration of gastric contents and combined drug toxicity. During his six-day admission, Mr SWX received 64 doses of 11 medications with …
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