3,476 results
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…
29y · Male·ligature compression of the neck (hanging)
Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
Male·Combined effects of multiple blunt force injuries and the effects of fire (Craig…
Craig Whitall, a 49-year-old on methadone maintenance therapy, drove erratically on the Princes Highway after leaving hospital on Boxing Day 2017, colliding head-on with the Falkholt family vehicle, killing five people. …
77y · Male·early pneumonia in an elderly man receiving terminal palliative medical care for…
James Tilbury, a 77-year-old long-term prisoner, died from early pneumonia while receiving palliative care for an atypical brain meningioma. He had complex chronic conditions including COPD, prostate cancer, ischaemic he…
16y · Male·multiple injuries sustained in motor vehicle crash
A 16-year-old unlicensed driver died in a high-speed crash while being pursued by unmarked police over 14 km. The driver attempted a dangerous overtaking manoeuvre on a gravel verge while evading police. Two detectives i…
58y · Female·undetermined; possible mixed drug intoxication and/or adrenal insufficiency
Jennifer May Tilley, aged 58, died on 8 January 2018 with an undetermined cause, though mixed drug intoxication and adrenal insufficiency were potential contributors. She had complex medical conditions requiring chronic …
72y · Male·Multiple stab and incised wounds to the chest and neck
Barry Gray, aged 72, was killed by his 22-year-old neighbor John Woodruff on 16-17 May 2013. Woodruff had been diagnosed with first episode psychosis in prison and released on a Community Corrections Order (CCO) on 30 Ap…
49y · Male·hanging
A 49-year-old man with a history of PTSD, depression and anxiety died by suicide following police service of a warrant to vary a family violence intervention order. He learned for the first time on 2 December 2017 that h…
Death from fire exposure during bushfire - the finding does not concern individu…
On 18 March 2018, a major bushfire commenced in an electrical easement near Reedy Swamp and rapidly spread to the coastal town of Tathra on the NSW South Coast, destroying approximately 1,400 hectares of bushland and dam…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
15y · Male·ligature compression of the neck (hanging)
Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…
1y · Male·Global cerebral ischaemic injury following cardiorespiratory arrest of unknown c…
A 22-month-old boy died from global cerebral ischaemic injury following cardiorespiratory arrest of unknown cause in the setting of detected methylamphetamine exposure. He had multiple healing traumatic injuries (rib fra…
43y · Female·Multisystem organ failure and hypoxic/ischaemic encephalopathy following anaphyl…
Peta Hickey, a 43-year-old company executive with no cardiac history, died from anaphylaxis to CT coronary angiogram contrast after her employer commissioned an inappropriate screening program. The referral lacked clinic…
19y · Male·Hanging
Yohan Wepitiya-Gamage, a 19-year-old male remand prisoner with a history of psychosis and substance use, died by hanging in his cell at the Metropolitan Special Programs Centre in January 2016. Critical clinical lessons …
5y · Male·Hypoxic ischaemic encephalopathy due to near-drowning
A 5-year-old boy who could not swim drowned in a public aquatic centre after crossing from a shallow ramp area into a 1.2-metre deep main pool, unobserved by his parents. He was underwater for 90 seconds before being ret…
52y · Male·Stab injuries to the chest
Mark Edwards, a 52-year-old man, died by suicide via stab injuries to the chest on 11 December 2020. He had suffered a workplace injury in 2007 resulting in amputation of his right leg in 2017, chronic pain, multiple sur…
63y · Male·Drowning
Max Edward Loweke, aged 63, drowned after his car was washed off Delatite Road at Whiteheads Creek Ford during flooding on 4 January 2016. The coroner found that while drowning was the medical cause, the death was likely…
48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male
Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.