220 results
64y · Male·Unascertained natural causes
Paul Christopher George, a 64-year-old man with Borjeson-Forssman-Lehman Syndrome and dysphagia, died unexpectedly on 17 June 2024 while in the care of a support worker. He experienced repeated coughing fits during the d…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
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. …
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…
50y · Male·in-hospital cardiac arrest on a background of seizures and atheroembolic cerebro…
A 50-year-old man with bipolar affective disorder, hypertension, anxiety, depression and history of alcohol abuse died from in-hospital cardiac arrest on a background of seizures and atheroembolic cerebrovascular disease…
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 …
69y · Female·Effects of fire
Stephanie Rebernik, aged 69, died in a house fire in 2023. She had an acquired brain injury from 1980 with cognitive decline, poor risk identification, and a documented five-year history of unsafe fire-lighting behaviour…
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…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.