3,476 results
61y · Female·Ligature neck compression in the setting of blunt force head trauma
A 61-year-old woman of Bulgarian descent was fatally assaulted by her estranged husband in a domestic violence incident. She died from ligature neck compression following blunt force head trauma. The perpetrator had mult…
47y · Male·Hanging
A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…
67y · Male·acute gastrointestinal haemorrhage complicating peptic ulcer of the duodenum wit…
A 67-year-old man died from acute gastrointestinal haemorrhage from a duodenal ulcer following complex post-operative complications from laparoscopic Hartmann's procedure for diverticulitis. Key clinical lessons: (1) Ear…
26y · Female·Neck injury due to stabbing
A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…
27y · Male·multiple organ failure due to or as a consequence of heat stroke
Olivier Caramin, a 27-year-old Belgian national on a working holiday visa, died from heat stroke while picking pumpkins on 31 October 2017 in Far North Queensland. He was just three days into farm work without proper acc…
28y · Female·Complications of a seizure in the setting of prescription drug abuse (pregabalin…
Samantha Leech, 28, died from complications of a seizure in the setting of prescription drug abuse, particularly pregabalin. She obtained approximately 4000 pregabalin tablets over three months by visiting multiple GPs, …
24y · Male·multiple stab wounds to the chest that he inflicted upon himself
A 24-year-old man with diagnosed schizophrenia experienced a relapse and engaged in a dangerous spree involving vehicle theft, assault, and police pursuit. Despite psychiatric treatment with antipsychotics, he stopped me…
37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…
MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…
86y · Female·Plastic bag asphyxia
An 86-year-old woman with delirium, depression, and multiple cardiac comorbidities died by asphyxiation with a plastic bag while in a transitional care facility. She had expressed wishes to die, references to suicide, an…
40y · Male·Penetrating wounds to the chest
Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…
50y · Male·blunt trauma of the abdomen, pelvis and legs
Retbe Chide Negga, an Ethiopian-born seasonal farm worker, died from crush injuries after his leg became trapped beneath a trailer wheel while attempting to board a moving tractor-trailer at a cherry orchard. Key clinica…
1y · Male·Global cerebral ischaemia in an infant with upper airway obstruction
NB, a 14-month-old with a tracheostomy requiring overnight nursing support in foster care, suffered a cardiac arrest on 17 December 2016 that resulted in severe hypoxic brain injury and death. The overnight nurse (Ms Jar…
44y · Male·Strangulation
Ashley Phillips, aged 44, was strangled to death by Jason Considine during a consensual sexual encounter on 26 May 2017. This finding reveals systemic failures in community corrections case management. Considine was subj…
75y · Female·Multiple injuries including stab wounds to the chest
A 75-year-old woman was fatally stabbed by her son during a family violence incident. Her son had a 20-year history of schizophrenia and schizoaffective disorder with poor medication compliance, documented aggression tow…
36y · Male·multiple injuries consistent with a fall from a height
A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…
37y · Male·Combined drug toxicity (methadone, fentanyl, diazepam and pregabalin)
Daniel Joseph Herbert, aged 37, died from combined drug toxicity involving methadone, fentanyl, diazepam and pregabalin. He had a 17-year history of opioid dependence stemming from prescription OxyContin for a work-relat…
65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists
James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…
32y · Male·Multiple injuries sustained in a fall from a height
Adam Laufer, a 32-year-old man with longstanding bipolar disorder, died by suicide on 24 November 2016 when he jumped from the LaTrobe Street overpass in Melbourne. In the early hours of 24 November, his father called tr…
34y · Male·Cardiac tamponade due to hemopericardium from acute aortic dissection of the asc…
A 34-year-old previously healthy man presented to the ED with sudden-onset central chest pain. He was discharged with a diagnosis of GORD after negative troponin and symptomatic relief with antacids. A chest X-ray showed…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…
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