64y · Female·Haemorrhagic bronchopneumonia complicating doxepin overdosage
A 64-year-old woman died from doxepin overdose complicated by haemorrhagic bronchopneumonia. She had attempted suicide in April 1999 and was referred to a psychiatrist (Professor Schioldann) who prescribed sertraline. He…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
29y · Female·asphyxiation due to ligature compression of the neck (hanging)
Wendy Anne Eadie, 29, died by suicide in Graylands Hospital's Frankland Centre on 1 November 1998 while detained following charges of unlawful wounding against her parents. She had a longstanding history of depression, c…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…
Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …
0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…
Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr Renshaw diagnosed viral infection with possible reflux, admitted for observation, and managed co…
21y · Male·Suffocation from hanging
Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …
36y · Male·Combined effects of trihexyphenidyl (benzhexol) toxicity, amphetamine-type stimu…
A 36-year-old man with schizoaffective disorder, substance abuse issues, and undiagnosed cardiomyopathy died from combined toxicity of benzhexol (prescribed by his GP for tardive dyskinesia), amphetamine-type stimulants,…
74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …
Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…
19y · Male·Hanging (self-inflicted)
Jacob Van Berlo, a 19-year-old male, died by hanging following a suicide. He had a history of depression treated with sertraline and an uncontrolled gambling addiction. On the day of death, after receiving his weekly pay…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
40y · Male·neck compression consequent upon hanging
Ross Campbell, a 40-year-old man with a history of family violence perpetration, alcohol abuse, and undiagnosed mental illness, died by hanging. He had attended a Men's Behavioural Change Program in 2011 following a fami…
Male·chronic suppurative otitis media with secondary infection
An Aboriginal man died from complications of chronic ear disease (chronic suppurative otitis media) with secondary infection. He was incarcerated intermittently and presented to custody with known ear disease, but approp…
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