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…
84y · Male·Bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart di…
Maxwell Howard, 84, died from bronchopneumonia in the setting of pulmonary emphysema and hypertensive heart disease while admitted to a mental health acute unit under a Temporary Treatment Order. He had multiple comorbid…
42y · Male·Unascertained
A 42-year-old male of Korean nationality was found deceased in his apartment after an odour complaint. The body was severely decomposed, limiting forensic investigation. Post-mortem examination revealed no acute trauma, …
31y · Male·Gunshot injury to the head and neck (self-inflicted)
Nathan Barreto Sexton, 31 years old, died by suicide on 21 October 2023 near Merredin, Western Australia, from a self-inflicted gunshot wound to the head and neck. Prior to his death, he had committed serious armed offen…
29y · Male·ligature compression of the neck (hanging)
Houston Peel, a 29-year-old man, presented to Fiona Stanley Hospital ED at 4:35 am on 30 March 2023 with acute psychotic symptoms including auditory and visual hallucinations, bizarre behaviour, and paranoid ideation fol…
44y · Male·bronchopneumonia in the setting of combined drug effect
Leighton Wood, 44, died from bronchopneumonia in the setting of combined drug effect. He had schizoaffective disorder, anti-social personality disorder, and chronic polysubstance use disorder (alcohol, methylamphetamine,…
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…
76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…
Graham John Butler, aged 76, died from out-of-hospital cardiac arrest secondary to coronary artery atherosclerosis and diabetes whilst imprisoned at Acacia Prison. He had significant cardiac history including prior myoca…
40y · Male·aspiration pneumonitis with acute alcoholic hepatitis, pancreatitis, mixed drug …
Trent Ian Johnston, a 40-year-old man with a history of chronic paranoid schizophrenia, alcohol and substance abuse, died from aspiration pneumonitis complicated by mixed drug toxicity (codeine, morphine, diazepam, parac…
95y · Female·Acute intracranial haemorrhage
DRF, a 95-year-old woman with dementia, hearing impairment, mobility limitations, and mild cognitive impairment, died from acute intracranial haemorrhage following blunt head trauma. She had been living with her son UJN,…
65y · Female·Head and neck injuries sustained in a motor scooter incident
Sharon O'Neill, a 65-year-old novice rider, died from head and neck injuries sustained during a motorcycle training course at HART in Somerton, Victoria. While practicing acceleration and turning drills on an unfamiliar …
71y · Male·Subdural haemorrhage on a background of an unwitnessed fall and anticoagulation …
A 71-year-old man with diabetes, ischaemic heart disease and osteomyelitis presented with fever and hypoglycaemia. He met Red Zone sepsis criteria (lactate 4.5mmol/L) but antibiotics were significantly delayed—ceftriaxon…
4y · Male·Haemophilus influenzae septicaemia with superimposed respiratory tract infection
A 4-year-old previously healthy male presented to Katherine Regional Hospital on 10 September 2023 with fever and eye pain. He was examined, found to have tachycardia (HR 156) and fever (39.2°C), and diagnosed with viral…
77y · Female·Airways obstruction by tissue paper
A 77-year-old woman with depression, anxiety, and chronic pain died from airway obstruction by tissue paper at an aged care facility. She had expressed suicidal ideation, attempted self-harm, and was found with tissues i…
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…
61y · Female·Ischaemic heart disease due to coronary artery atherosclerosis
Ms Maxine Lorraine Sanderson, a 61-year-old SDA resident with intellectual disability, died suddenly from ischaemic heart disease due to severe coronary artery atherosclerosis with critical stenosis of the left anterior …
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
64y · Male·Complications of congestive cardiac failure on a background of cardiac hypertrop…
QBT, a 64-year-old man with complex medical and psychiatric history including schizophrenia, COPD, and hypertension, was admitted to Bendigo Hospital on an Assessment Order after police concerns about mental health deter…
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…
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