398 results
26y · Female·Multiple stab wounds
ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia
A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…
Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…
62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…
Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug toxicity. Postmortem toxicology revealed high-co…
44y · Male·Drowning due to head injury due to impact with yacht
Rickie James Makin, 44, fell overboard from the 44.7-foot racing yacht Lady Helena in heavy seas during a competitive yacht race on Moreton Bay, Queensland, on 7 March 2020. He was not wearing a personal flotation device…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…
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 …
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…
31y · Male·Drowning
Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…
19y · Female·multiple injuries sustained in a train incident
JVM was a 19-year-old with major depressive disorder, anxiety, and possible first-episode psychosis who died by suicide after jumping in front of a train. She had multiple psychiatric admissions and was under care of St …
21y · Male·drowning
A 21-year-old male with schizophrenia and cannabis use died by suicide after jumping from the Tasman Bridge. He had been admitted to Royal Hobart Hospital on 7 May 2019 with suicidal ideation and auditory hallucinations …
3y · Female·Bilateral Bronchopneumonia (Streptococcus Pyogenes/Staphylococcus Aureus) with k…
Jade, a 3-year-old First Nations child, died from bilateral bronchopneumonia with neglect as a significant contributing factor. Her death was wholly preventable. The coroner identified critical failures: DCJ's Muswellbro…
26y · Male·Cardiomegaly in a man with Prader-Willi syndrome
Caine David Knight, aged 26, died from cardiomegaly with right ventricular hypertrophy in the context of Prader-Willi syndrome and severe obesity. He had a complex medical history including obesity hypoventilation syndro…
33y · Male·unascertained
Dean Jenkins, a 33-year-old with a history of drug use, disappeared on 24 August 2016 after being observed acting paranoid and erratically while substance-affected. His remains were found in a burrow near Woorinen in Feb…
40y · Female·Stab wounds to the chest and abdomen
A 40-year-old woman was fatally stabbed by her former intimate partner who had an extensive history of family violence offending and multiple breaching intervention orders. Despite multiple service contacts in the days b…
57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)
Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…
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