212 results
66y · Female·Pneumonia (with Trisomy 21 and dementia as contributing conditions)
Voula Hristeas, a 66-year-old woman with Down syndrome, dementia, and intellectual disability, died of pneumonia on 31 March 2024 at her supported disability accommodation home. She had been admitted to hospital on 21 Fe…
76y · Male·out-of-hospital cardiac arrest in a man with coronary artery atherosclerosis and…
Graham John Butler, aged 76, was a sentenced prisoner at Acacia Prison who died from out-of-hospital cardiac arrest caused by coronary artery atherosclerosis in the context of long-standing type 2 diabetes, hypertension,…
47y · Male·Pneumonia
Shawn Farlech, a 47-year-old man with acquired brain injury from childhood encephalitis living in specialist disability accommodation, died from pneumonia with sepsis. He presented with fever on 8 April and was initially…
41y · Male·complications of acute ethanol toxicity
Mr RJ, a 41-year-old man with a history of progressive alcohol misuse and mental health conditions (anxiety and depression), died from complications of acute ethanol toxicity following cardiac arrest due to aspiration an…
50y · Female·hanging
A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …
73y · Female·Complications of lipoid pneumonia following the ingestion of shampoo, conditione…
Judith Pollard, a 73-year-old woman with an extensive mental health history, was voluntarily admitted to Shepparton Private Hospital on 1 June 2023 following acute depression and paranoia. Despite her family informing st…
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
23y · Female·unascertained
Olivia Gilfillan, aged 23, died between 1–5 February 2018 after nine years of psychiatric treatment for anorexia nervosa, obsessive-compulsive disorder, schizoaffective disorder, and borderline personality disorder. She …
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …
61y · Female·Complications of a rectal prolapse
Susan Maree Lawless, a 61-year-old woman with intellectual disability due to untreated phenylketonuria, died from complications of a rectal prolapse while residing in supported disability accommodation. She was found unr…
36y · Female·multiple blunt force injuries sustained after intentional self-infliction by fal…
Fiona Goodberg, a 36-year-old nurse with prior OCD history, died by falling from Landslide Lookout on 29 October 2020. She had experienced severe postpartum obsessive-compulsive disorder (OCD) following her daughter's bi…
62y · Female·Effects of fire
A 62-year-old woman died in a house fire that originated from an unattended cooking pot on the stovetop left in the 'on' position. She had a history of bipolar disorder managed with medication and sertraline, and signifi…
43y · Female·Combined drug toxicity (tapentadol, sertraline, gabapentin, periciazine, carbama…
A 43-year-old woman with complex psychiatric history including schizoaffective disorder, borderline personality disorder, and chronic suicidality died from combined drug toxicity involving eight medications (tapentadol, …
50y · Female·Combined drug toxicity in a woman with tension pneumothorax
Suzanne Evans, aged 50, died from combined drug toxicity in the setting of tension pneumothorax. She had a history of alcohol dependence, depression, and borderline personality disorder. Following an argument with her pa…
39y · Male·Drowning in the setting of a very high blood alcohol level
Frank Mellia, age 39, drowned in the Yarra River after entering the water with a very high blood alcohol level (0.33g/100mL). He was not a confident swimmer and had a history of anxiety, depression, and alcohol misuse. H…
32y · Female·Hypoxic-ischaemic encephalopathy due to hanging
Chloe Jane Campbell, aged 32, died by suicide while an involuntary inpatient with borderline personality disorder, complex PTSD, and chronic suicidal ideation. She was admitted 18-30 April 2019 after ceasing medications …
36y · Male·Neck compression secondary to hanging
A 36-year-old man with a history of depression, anxiety, and alcohol dependence died by suicide during the COVID-19 pandemic following job loss. He presented to a psychotherapist with suicidal ideation, multiple risk fac…
18y · Male·Sodium nitrite toxicity
Nathan Greenwood, an 18-year-old with a history of anxiety and depression managed in primary care, died from sodium nitrite toxicity after intentionally consuming 30 grams of the substance. He had been under care at his …
Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…
Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…
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