3,490 results
30y · Male·unknown - no postmortem examination performed
This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…
54y · Male·Complications of pelvic and spinal fractures sustained in a fall in man with Dow…
Andrew William Barr, a 54-year-old man with Down syndrome and Alzheimer's dementia, died from complications of pelvic and spinal fractures sustained in a fall. Following his mother's death in January 2021 and his Februar…
2y · Male·Complications of malnutrition
GFD, a 2-year-old boy, died from complications of malnutrition and dehydration on 3 July 2021. Post-mortem examination revealed severe undernutrition, chronic malnutrition, and significant dehydration with hypernatraemia…
88y · Female·Complications of cholecystectomy surgery
Margaret Mariani, 88, died from complications of laparoscopic cholecystectomy for gallstone-induced pancreatitis. An iatrogenic small bowel perforation, likely caused by inadvertent suturing during closure, led to perito…
45y · Male·Diabetic ketoacidosis with multi-organ failure caused by pneumonia
A 45-year-old Aboriginal man with poorly managed diabetes and schizophrenia presented to Cowra District Hospital ED with lethargy, cough and fever. Despite being triaged as category 2 (urgent) with abnormal vital signs i…
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…
42y · Female·pneumonia with diffuse alveolar damage in the setting of mixed drug toxicity (Ba…
Allyson Bailey, a 42-year-old woman with complex polysubstance use disorder and borderline personality disorder, died from pneumonia with diffuse alveolar damage complicated by mixed drug toxicity (baclofen and pregabali…
17y · Female·Self-inflicted hanging in the context of known complex mental health and behavio…
Didbala, a 17-year-old Aboriginal girl with complex mental health conditions including psychosis, bipolar disorder and suspected FASD, died by hanging at a CASPA residential care house in Katherine on 3 October 2022. She…
34y · Male·unascertained (suspected suicide, but body not located so no post-mortem examina…
Simon Harrington, a 34-year-old man with depression and psychotic features, disappeared on 10 January 2011 after starting a new job that triggered anxiety. He had previously attempted suicide in 2008. His sister Michelle…
0y · Male·Non-accidental infliction of significant force to the head/face and gum region, …
Jacob, a premature infant born at 29 weeks, was discharged from neonatal care at 11 weeks old and presented to hospital three days later with a subarachnoid haemorrhage and periorbital bruising. Despite being assessed as…
62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…
Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…
59y · Male·Multiple stab injuries
A 59-year-old man was fatally stabbed by his former partner in a context of longstanding family violence. The deceased had perpetrated significant violence against the perpetrator, who had mental illness and housing inst…
28y · Male·Cardiac arrhythmia
Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropria…
82y · Female·Peritonitis due to leakage of bowel contents from bowel anastomosis following el…
Winifred Carpenter, 82, died 11 days after a right hemicolectomy for colon cancer from peritonitis due to anastomotic leak. Critical failures occurred on discharge day (10 March 2023): clinicians did not recognize her de…
27y · Female·Multiple blunt force injuries in the context of a single vehicle rollover
Grace Moulding, a 27-year-old British woman, died in a single-vehicle rollover on the Sandover Highway while driving an unregistered Art Centre vehicle at an estimated 116 km/h on an unsealed road. Critical failures incl…
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug toxicity. Postmortem toxicology revealed high-co…
Unknown·Panella: pulmonary thromboembolism due to left calf deep vein thrombosis; Skeffi…
Three South Australians died following extended waits on ambulance ramps outside metropolitan hospitals. Anna Panella (76) died from pulmonary thromboembolism; Bernard Skeffington (89) died from aspiration pneumonia afte…
25y · Male·Electrocution
Jordan Robert Crocker, a 25-year-old qualified electrician, was fatally electrocuted in a roof space while diagnosing a U4 fault code on a Daikin ducted air conditioner system. The circuit supplying the air conditioner w…
86y · Male·Complications of blunt force trauma in a man with cardiac amyloidosis and athero…
An 86-year-old man with dementia, cardiac amyloidosis and atherosclerotic cardiovascular disease died from complications of blunt force trauma sustained in an assault by his adult son. The deceased had been diagnosed wit…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…
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