89 results
32y · Male·self-inflicted hanging
Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…
24y · Male·Head injury from explosion
A 24-year-old man died when his hired truck's cargo compartment exploded while driving. The rear compartment contained three LPG gas cylinders (domestic barbeque bottles), all found with partially open valves. Gas leaked…
27y · Male·Complications of snake bite
Shane Kyle Tatti, a 27-year-old gardener, died from complications of tiger snake envenomation. After a vigorous bite on 6 November 2014, he received one vial of tiger snake antivenom at Orbost Hospital 62 minutes post-bi…
55y · Male·Combined effects of mixed drug (alcohol and promethazine) toxicity and environme…
A 55-year-old man with alcohol dependency died from combined alcohol and promethazine toxicity with heat exposure. He spent 4-5 hours sunbaking in high temperatures (exceeding 30°C) while heavily intoxicated and sedated …
57y · Female·Positional asphyxia caused by the combined effect of consumption of several opia…
57-year-old woman with chronic pain died from positional asphyxia caused by consumption of multiple sedative medications. She was prescribed opioids (Fentanyl, Oxycodone) and Pregabalin, but also obtained Dolased and Pro…
22y · Male·combined mixed drug intoxication
A 22-year-old medical student with chronic spinal cord pain and depression died from combined drug intoxication involving U-47700 (a potent uncontrolled synthetic opioid 7.5 times more potent than morphine), venlafaxine …
53y · Male·Steven Hitchins: plastic bag asphyxiation; Shawn Gudge: hanging
Two inpatient suicides in a Queensland mental health unit highlight systemic failures in environmental hazard management and observation practices. Steven Hitchins (age 53) died by asphyxiation with a plastic bag in 2014…
61y · Male·mixed prescription drug toxicity (methadone, diazepam, promethazine) with aspira…
A 61-year-old man with chronic alcoholism, dilated cardiomyopathy and cirrhosis died from mixed prescription drug toxicity (methadone, diazepam, promethazine) with aspiration pneumonia. He consumed significant alcohol on…
39y · Male·Complications of large bowel pseudo-obstruction
A 39-year-old man with schizo-affective illness, hepatic cirrhosis, and substance abuse history died from complications of large bowel pseudo-obstruction with aspiration pneumonia. He had been admitted involuntarily for …
35y · Female·combined drug toxicity
A 35-year-old woman with long-standing substance use disorder, depression, and chronic pain died from combined drug toxicity involving methadone, pregabalin, methamphetamine, benzodiazepines, mirtazapine, promethazine an…
0y · Female·Pneumonia in an infant with surgically repaired congenital heart disease, premat…
A 9.5-month-old girl with complex medical history (prematurity at 29 weeks, congenital heart disease status post multiple repairs, necrotising enterocolitis with ileostomy, failure to thrive) died from acute pneumonia ca…
24y · Male·mixed ethanol and prescription drug toxicity
Nathan Lunson, aged 24, died from mixed ethanol and prescription drug toxicity following an impulsive overdose. He had longstanding borderline personality disorder, polysubstance dependence, chronic suicidal ideation, an…
68y · Female·Multiple injuries sustained in a fall
68-year-old woman with bipolar affective disorder and history of suicide attempts died by jumping from a car park rooftop on 14 April 2015. She had been discharged from psychiatric inpatient care to aged care on 2 March …
6y · Male·pneumonia complicating influenza A (H1N1) infection with secondary streptococcal…
Sebastian Parman, a 6-year-old boy, died from pneumonia complicating influenza H1N1 with secondary group A streptococcal infection causing scarlet fever, empyema and sepsis. Multiple clinical failures contributed: an inf…
15y · Male·Global ischaemic brain injury post cardiac arrest secondary to anaphylaxis
Jack Glen Irvine, a 15-year-old with documented severe nut allergies and asthma, died from anaphylaxis triggered by consuming a macadamia nut cookie at a Victorian Karting Association camp. The cookie was provided despit…
15y · Female·Hanging
Zakiya, a 15-year-old Barkindji Maraura woman, died by hanging at Mildura Base Hospital following a family argument about repaying a borrowed $300. She had disclosed experiences of childhood sexual abuse by her uncle, ph…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
2y · Female·pneumonia in a child with reported recent flu-like illness (multiple viral detec…
Armarnie-Bree Elliott, a 2-year-old with Angelman syndrome, died from pneumonia complicated by oxycodone toxicity. She developed flu-like symptoms in late April while at a women's refuge. On 2 May evening, appearing incr…
41y · Male·multiple injuries sustained in motor vehicle collision
Roberto Di Bartolo, a 41-year-old renderer with a history of depression and previous suicidal ideation, died from multiple injuries sustained in a high-speed motor vehicle collision on the Hume Highway near Seymour. On t…
80y · Male·Drowning
An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…
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