48 results
82y · Female·bilateral pulmonary thromboembolism due to left calf deep vein thrombosis
Jean Harrap, 82, died from bilateral pulmonary embolism secondary to left calf deep vein thrombosis while detained under a Mental Health Act Inpatient Treatment Order. She presented to ED with altered mental state, self-…
22y · Male·acute blood loss from incised injuries to left forearm
Simon Smith, a 22-year-old with end-stage renal failure requiring dialysis and complex comorbidities, died by suicide during hospitalization. Despite multiple psychiatric assessments finding he had capacity to make treat…
32y · Male·Complications of mixed drug use
A 32-year-old man with schizoaffective disorder and polysubstance abuse disorder died from complications of mixed drug use after boarding a train in an intoxicated state. He remained slumped in a train seat for nearly th…
79y · Male·Bronchopneumonia and acute bronchiolitis
Donald Broadribb, 79, died of bronchopneumonia and acute bronchiolitis after presenting to York Hospital on 12 October 2012 with vomiting, cough, and abdominal pain. He was discharged after nurses focused on treating con…
45y · Female·Multi-drug toxicity
Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …
54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…
Gabriele Hannemann, a 54-year-old woman with severe post-polio quadriplegia and chronic respiratory failure, died suddenly at home during consensual sexual activity. She had severely compromised lung function (13% predic…
31y · Female·plastic bag asphyxia
Kirstan McRae-Jansen, a 31-year-old woman with chronic schizophrenia, borderline personality disorder, and substance abuse, died by plastic bag asphyxia using an LPG bottle. She was under Community Treatment Order with E…
Christopher Salib: ischaemic heart disease with multiple prescription drug toxic…
This landmark inquest examined three deaths involving prescription drug toxicity: Christopher Salib (24, ischaemic heart disease with drug toxicity), Nathan Attard (34, multi-drug toxicity), and Shamsad Akhtar (35, multi…
45y · Female·Combined Drug Toxicity
Christina Mifsud, aged 45, died from combined drug toxicity including methadone, diazepam, paroxetine and cannabis. She accessed methadone prescribed to her partner stored unsecured in their home. The coroner identified …
37y · Male·compression of the neck consistent with hanging
Andrew David Hollonds, a 37-year-old man with personality disorder, substance misuse, and recent psychosis, presented to hospital after a suicide attempt (temazepam overdose) following job loss. He explicitly threatened …
55y · Male·Immersion
Peter Fisher, a 55-year-old man with schizophrenia and depression, died from immersion after becoming homeless. Discharged from The Alfred Hospital in February 2007 to supported accommodation without a Community Treatmen…
51y · Female·Multiple injuries sustained when struck by a car while lying on the Mornington P…
Lee Collings, 51, died by suicide after absconding from an Emergency Department. She presented with suicidal ideation and was triaged as Mental Health Category 4. Key failures included: the Crisis Assessment Team clinici…
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
37y · Male·Gunshot injury to head
Senior Constable Anthony Hogarth Clarke, a 37-year-old experienced police officer, was shot and killed during a drink-driving intercept on 24 April 2005. The offender obtained Clarke's revolver from his holster during a …
26y · Male·Gunshot injury to the head (self-inflicted)
Mark Bailey, a 26-year-old with obsessive compulsive disorder, anxiety, alcohol dependence, and a history of violence, died from a self-inflicted gunshot wound. He was under treatment by a psychiatrist and psychologist w…
58y · Male·adenocarcinoma of the right lung
Barry John Hockey, a 58-year-old prisoner, died of advanced lung adenocarcinoma with metastatic disease and acute bronchopneumonia while in the Princess Alexandra Hospital Secure Unit. He presented in November 2007 with …
38y · Male·self-inflicted hanging
Paul James Guarini, a 38-year-old university student with a history of relationship difficulties, suicide attempts, and depression, died by hanging in Cowdy ward at Royal Darwin Hospital on 14 September 2007, within 10 m…
71y · Male·hypoxic brain injury due to hanging
A 71-year-old farmer with a 10-year history of major depressive disorder with melancholic features died by hanging on 22 July 2005, three days after admission to a private psychiatric hospital (Belmont) following a medic…
54y · Male·Global cerebral hypoxic injury due to or as a consequence of status epilepticus
Terence James Robinson, 54, died from status epilepticus causing global cerebral hypoxic injury after 16 days at Belmont Private Hospital. He was admitted following a violent altercation with police and attempted suicide…
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