212 results
40y · Male·Injuries sustained in a fall from height
Daniel McKindley, 40, died from injuries sustained in a fall from the 16-metre platform of Poppet Head Lookout tower in Bendigo. He had depression and anxiety treated by his GP with antidepressants (mirtazapine then sert…
69y · Female·unascertained
Christine Pearl Stroner, 69, died of an unascertained cause on the evening of discharge following laparoscopic cholecystectomy and hiatus hernia repair at Fremantle Hospital. She was observed at 2pm with tachycardia (HR …
50y · Female·Hanging
Jacinta Dwyer, a newly appointed magistrate with limited criminal law experience, developed severe anxiety and depression within months of taking office in February 2017. Despite supportive interventions from senior judg…
85y · Male·pneumonia
An 85-year-old man with multiple comorbidities (ischaemic heart disease, COPD, atrial fibrillation, dementia) died from pneumonia while in custody at Port Phillip Prison. He developed a lower respiratory tract infection …
64y · Male·Multiple injuries sustained in an explosion
A 64-year-old explosives expert died from multiple injuries sustained in a workplace explosion while blasting rock at a construction site. After initial charges largely misfired, Mr Low failed to follow established Austr…
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
46y · Female·acute mixed drug toxicity due to accidental self-administered drug overdose
Dr V., an obstetrician-gynaecologist trainee, died from acute mixed drug toxicity on 18 January 2013 following self-administration of multiple anaesthetic drugs (propofol, midazolam, fentanyl, alfentanil) via intravenous…
33y · Male·Opiate toxicity
A 33-year-old man with previously unrecognized obstructive sleep apnoea was admitted with severe headache. The treating physician prescribed a complex regimen of escalating opiate doses including both slow-release (MS Co…
91y · Female·Unascertained
Margaret Smith, a 91-year-old admitted with head strike from fall, developed moderate depression during her stay and received electroconvulsive therapy (ECT) as a compulsory patient. On 5 March 2015, she developed epigas…
53y · Male·Coronary atherosclerosis; chronic obstructive airways disease; chronic cholecyst…
Gregory Bert Smallwood, a 53-year-old prisoner with morbid obesity, hypertension, diabetes, and COPD, died from acute myocardial infarction due to severe coronary atherosclerosis. He called for help at 3:06am reporting i…
28y · Female·Head injury
A 28-year-old experienced horse trainer, Danielle Lewis, died from a head injury after being thrown from a sulky at a harness racing facility. She was struck headfirst against a building wall after the sulky wheel caught…
70y · Female·bronchopneumonia
Margaret Jane Gardiner, aged 70, died from bronchopneumonia while an involuntary inpatient at an aged psychiatry unit. She had longstanding anxiety, depression, and eating disorder with recent significant physical and me…
60y · Female·Complications of metastatic melanoma in the setting of neck of femur fracture fo…
Susan Ruth Lovell, a 60-year-old woman, died from complications of metastatic melanoma in the setting of a neck of femur fracture sustained during a fall. A skin lesion on her left calf, noted in January 2010, was clinic…
23y · Male·combined drug toxicity (oxymorphone, benzodiazepines, codeine, and morphine) in …
Jonas Jvirblis, a 23-year-old PhD student, died from combined drug toxicity (oxymorphone, benzodiazepines, codeine, and morphine) in the setting of sarcoidosis. He had a long history of substance abuse and anxiety disord…
37y · Male·Hanging
Andrew Stanyer, a 37-year-old male with significant life stressors, died by hanging after police attendance at a family violence incident. He had previous suicide attempts (2000, 2009), depression treated with sertraline…
24y · Female·Pentobarbitone toxicity
24-year-old Daniella Sessarego died from pentobarbitone toxicity following intentional ingestion. She had borderline personality disorder and depression with a history of self-harm and suicidality. On 12 August 2014, she…
62y · Male·Multiple injuries post motor vehicle accident (fire truck)
Mr Hugh Neville Monroe, 62-year-old experienced CFA volunteer driver, died from multiple injuries when his fire tanker collided with trees while negotiating a right-hand bend on Spring Creek Road. Investigation revealed …
46y · Female·Multiple severe trauma suffered in a motor vehicle accident
A 46-year-old woman died in a head-on motor vehicle collision after her car drifted across the centre line on the Bass Highway. She had reported feeling tired earlier that morning and had intended to pull over to sleep. …
56y · Male·Gunshot wounds to the head
Terence and Christine Hodson were discovered shot dead in execution-style killings at their home in Kew, Victoria on 16 May 2004. The coroner investigated whether police informer Terence Hodson's death was connected to h…
71y · Male·Sepsis due to bronchopneumonia and sacral ulcer
Mr John Knight, aged 71, died from sepsis secondary to bronchopneumonia in a psychiatric inpatient unit after five months admission for frontotemporal dementia management. His complex behavioural and cognitive decline re…
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