3,476 results
42y · Male·Blunt force head and chest injuries caused by a traffic crash where he was the d…
Patrick Wayne Bloomfield, a 42-year-old Aboriginal man, died from blunt force head and chest injuries when his vehicle rolled on the Plenty Highway after police initiated a pursuit from a random breath testing (RBT) stat…
40y · Female·Cerebral oedema of unknown aetiology with probable contribution from Hashimoto's…
Sarah Louise Rose, aged 40, died from cerebral oedema of unknown aetiology with probable contribution from Hashimoto's encephalopathy. She had been diagnosed with Hashimoto's thyroiditis in late 2011 and prescribed thyro…
47y · Male·sequelae of ruptured brain aneurysm
John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…
56y · Male·Hanging
A 56-year-old man with a long history of bipolar affective disorder and alcohol misuse died by hanging between 18–20 December 2018. He presented to hospital on 16 December after expressing suicidal intent (plan to overdo…
68y · Male·surgical complications following laparoscopic cholecystectomy for cholecystitis,…
Cyril Churchill, a 68-year-old man with multiple comorbidities, died from surgical complications after laparoscopic cholecystectomy for acute cholecystitis. Postoperatively, he developed profound hypotension. The treatin…
32y · Male·unascertained; most likely exposure after walking in bushland
Jason Marcus Lawson, a 32-year-old man with a complex psychiatric history including depression, anxiety, polysubstance use, and previous suicide attempts, disappeared on 11 December 2003, one week after discharge from an…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
15y · Female·methylamphetamine and methadone toxicity
Becky, aged 15, died on 26 March 2016 from methylamphetamine and methadone toxicity at a private residence in Armidale, NSW. She was in the parental responsibility of the Department of Family and Community Services (FACS…
44y · Female·Unascertained
Ms Lina Huynh, a 44-year-old woman of Vietnamese descent with limited English, died on 7 September 2017 from unascertained causes following severe head and facial trauma inflicted by her de facto partner during a methamp…
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
35y · Female·Stab wounds to the chest
Chan Chen, 35, was killed by her husband Andrew Luo in their home through stab wounds to the chest. Luo had displayed increasingly erratic behaviour throughout 2019, including delusions of persecution, beliefs that Chen …
26y · Male·Plastic bag asphyxia in the setting of a vitiated atmosphere with inert gases
Jack Watson, 26, died by intentional asphyxiation with inert gas on 2 August 2016. He had a long history of mental health issues including ADHD, depression and suicidal ideation. Following acute psychiatric admission to …
2y · Male·traumatic head injury
A 2-year-7-month-old boy died from traumatic head injury inflicted by person(s) unknown after experiencing severe and escalating physical abuse over weeks. Despite 13 reports to FACS (now DCJ) between 2010-2012, includin…
49y · Male·Stab wound to the chest
A 49-year-old man with anxiety and depression died from a self-inflicted stab wound to the chest sustained during police response to a domestic violence call. He had brought tools and weapons to his ex-partner's home. Wh…
87y · Female·closed traumatic head injury from a fall at standing height; significant contrib…
An 87-year-old woman with dementia, congestive cardiac failure, and diabetes sustained a fatal closed head injury from a fall in her aged care room overnight. The coroner found that the responsible ECA did not perform th…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
40y · Male·Mixed drug toxicity
Shae Paszkiewicz, a 40-year-old man with a long history of drug dependence and incarceration, died from mixed drug toxicity five days after being found unconscious following opioid injection. He had been released from pr…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…
48y · Male·hanging
Dimitrios Mavris, a 48-year-old man arrested for drug importation, died by hanging in the Surry Hills Cells Complex on 25 May 2018, approximately 40 hours after being taken into custody. He was initially assessed as pres…
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