212 results
48y · Male·Complications of metastatic melanoma
A 48-year-old man in custody at Port Phillip Prison died from complications of metastatic melanoma at St Vincent's Hospital. He had been diagnosed with melanoma in 2016 and developed metastatic disease in 2019. After pre…
47y · Female·Overdose of hydromorphone
A 47-year-old woman died from an intentional overdose of prescribed hydromorphone while residing at a domestic violence refuge. She had a history of depression, previous suicide attempts, and was in crisis following sepa…
28y · Male·Gunshot wound to the head
Christopher George, a 28-year-old man with a history of depression and suicidal ideation, died from a self-inflicted gunshot wound while police conducted a welfare check at his home. He had stopped taking sertraline (ant…
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…
59y · Male·mixed drug toxicity (tramadol and sertraline), likely serotonin syndrome
A 59-year-old man died from mixed drug toxicity involving tramadol and sertraline, likely precipitating serotonin syndrome. He was prescribed tramadol 150mg morning and 100mg evening (total 250mg daily), but evidence ind…
31y · Male·Aspiration Pneumonia
Peter Bain, a 31-year-old man with severe intellectual disability, autism, and multiple comorbidities, died from aspiration pneumonia. He was admitted to ICU following deterioration at a DHHS residential facility and die…
34y · Female·Complications of fall with fractured ankle and subsequent deep venous thrombosis…
Anna Bowditch, aged 34, died from complications of deep venous thrombosis (DVT) with pulmonary embolism and paradoxical stroke following elective fracture repair surgery. She had multiple known DVT risk factors: immobili…
56y · Male·unascertained; presumed suicide by unknown means
Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 September 2016. The coroner found on the bala…
38y · Female·Complications of decompensated liver failure due to cirrhosis secondary to Hepat…
Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to re…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
26y · Female·Multiple drug toxicity
Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …
Female·Miranda Howard: aspiration pneumonia complicating overdose of prescription medic…
Two young women with borderline personality disorder (BPD) died by suicide after inadequate mental health care in South Australia. Miranda Howard (22) died from aspiration pneumonia following overdose; Aurora McPherson-S…
21y · Male·Hanging
A 21-year-old male died by hanging on 9 December 2018 following arrest for drink-driving with a blood alcohol concentration of 0.155g/210L. He had been prescribed sertraline 50mg by his GP on 7 November 2018 for depressi…
34y · Male·Hanging
Errol Handog, a 34-year-old man presenting with anxiety, was assessed by psychiatry on two consecutive days at Nepean Hospital and discharged to community care despite suicidal ideation. A key clinical lesson is that inc…
22y · Female·Hypoxic-ischaemic encephalopathy due to asphyxia (mechanical asphyxiation by nec…
A 22-year-old woman died from asphyxia following strangulation by her boyfriend with schizophrenia. The boyfriend was under mental health service care at Princess Alexandra Hospital. The coroner found his mental health t…
78y · Male·Neck injuries received in a fall
A 78-year-old man with Ménière's disease and depression died from neck injuries sustained in a fall from a ladder while using an electric hedge trimmer in his garden. He was found deceased by a friend after missing a reg…
34y · Male·drowning
A 34-year-old man with schizoaffective disorder drowned after attempting to surf in dangerous conditions on 31 December 2015. He had been under community mental health care with fragmented coordination between public and…
33y · Female·blunt impact injuries to neck and chest
A 33-year-old woman with depression, anxiety, and emerging psychotic symptoms presented to the ED on two consecutive days (26 and 28 October 2013). Following the first presentation, she was assessed by a psychiatric nurs…
75y · Male·Hanging
Peter Nolan, a 75-year-old man with depression, chronic pain, alcohol dependence, and recent suicide attempts, died by hanging in an aged psychiatric mental health unit. He was admitted to Broadmeadows Aged Psychiatric M…
42y · Male·sudden unexpected death in epilepsy (SUDEP)
A 42-year-old Aboriginal man with longstanding epilepsy, double-leg amputation, and alcohol abuse history died at home from sudden unexpected death in epilepsy (SUDEP). He was under Guardianship and Administration Act or…
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