212 results
74y · Female·Diabetic ketoacidosis
A 74-year-old woman with Type 1 diabetes died from diabetic ketoacidosis (DKA) in an aged care facility. Between 7-10 December 2016, her blood glucose levels remained persistently elevated (>33 mmol/L) despite escalating…
34y · Female·Drowning
Ozlem Karakoc, aged 34, died by drowning on 14 July 2017 at her home in Dandenong, Victoria. She was murdered by her former intimate partner, Murat Davsanoglu, who held her underwater in a bathtub. Ms Karakoc had mild in…
31y · Male·hanging
Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm h…
60y · Female·undetermined; natural causes not excluded (possible paraganglioma infarction, pn…
A 60-year-old woman with depression, recent acute kidney injury from dehydration, and suicidal ideation was discharged from hospital on 27 August 2021 after psychiatric improvement. She was prescribed increased Sertralin…
Male·Darren Wallace: single gunshot wound to right side of neck. TBD: two self-inflic…
Two deaths occurred on 9 December 2015 in a tragic incident connected to a dispute within the Rebels Outlaw Motorcycle Gang. TBD, a 31-year-old former ADF member with severe post-traumatic stress disorder (PTSD), alcohol…
73y · Female·atherosclerotic and hypertensive coronary vascular disease
Ms Wallace, a 73-year-old woman with hypertension and other comorbidities, developed atrial fibrillation during orthopaedic surgery for a fibula fracture. She was discharged on flecainide 50mg daily, metoprolol, and riva…
33y · Female·hanging
A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon monoxide poisoning attempt. The coroner found that discharge…
42y · Female·hanging
Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…
24y · Male·Gunshot wounds to the chest and abdomen
Jesse Aaron Kermode, 24, died after being shot by police at Ipswich Railway Station on 16 September 2018. He had a longstanding history of treatment-resistant schizophrenia and substance abuse, with repeated documented p…
50y · Male·Gunshot wounds to the chest
Mark Sheppard, aged 50, died from gunshot wounds sustained during a police response to a hoax emergency call at a caravan park. He had terminal end-stage COPD with alpha-1 antitrypsin deficiency and was using home oxygen…
36y · Male·Multiple Sharp Force Injuries to Chest and Neck
Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with GP support after achieving 3 years …
42y · Female·Choking on a food bolus
Deva Frijlink, aged 42 years with intellectual disability and schizoaffective disorder, died from choking on a food bolus during a supervised mealtime excursion. She was under the care of a support worker at a shared acc…
50y · Female·Hanging
A 50-year-old woman died by hanging in December 2017 after a relationship characterised by family violence and her own depression. She had been in an intimate partner violence situation for years, had presented to ED wit…
36y · Male·Gunshot wounds to the chest and abdomen
Daniel Lewis, aged 36, died from gunshot wounds after police responded to a domestic violence call. Lewis had a history of brain injury from age 11, substance abuse, mental health issues including PTSD and drug-induced p…
Male·Complications of alcohol and hepatitis C-related liver disease
Peter Young, an Aboriginal man with advanced alcoholic cirrhosis and recently acquired hepatitis C infection, died of multi-organ failure while on remand in custody. He received appropriate standard medical care in priso…
40y · Female·combined drug toxicity (clomipramine, sertraline, diazepam, and quetiapine)
Linda-Jane Tatterson, aged 40, died from combined drug toxicity involving clomipramine, sertraline, diazepam, and quetiapine. She had a longstanding history of depression, OCD, and recurrent overdoses between 2014-2016. …
79y · Male·Complications of ischaemic heart disease
HV was a 79-year-old man who died in custody at Port Phillip Prison from complications of ischaemic heart disease. He had significant cardiac history including previous myocardial infarction, atrial fibrillation, pulmona…
72y · Male·Hanging
A 72-year-old male inmate at Long Bay Correctional Centre died by hanging in April 2017. He had a documented history of depression managed with antidepressant medications, and his medication (mirtazapine) was adjusted tw…
47y · Male·Pneumonia (1(a)), Motor neurone disease (1(b))
Raymond Cassar, a 47-year-old man with motor neurone disease requiring ventilatory support, died of pneumonia at a disability accommodation service. He had been diagnosed with a chest infection on 19 June 2018 and prescr…
38y · Male·Mixed drug toxicity
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…
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