3,478 results
60y · Male·burn wounds and the consequences thereof
CD, a 60-year-old man with long-standing psychiatric history (schizophrenia/schizoaffective disorder) and alcohol use disorder, set his house alight on 19 September 2017 after becoming acutely unwell with paranoid ideati…
92y · Male·Ischaemic heart disease and cardiomegaly in the setting of a fall in a man with …
A 92-year-old C4 quadriplegic man with ischaemic heart disease and cardiomegaly died following a fall at home. Two scheduled disability support shifts (1:00pm and 8:30pm) failed on 31 January 2019 due to staff rostering …
30y · Male·ligature compression of the neck (hanging)
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…
42y · Male·ischaemic heart disease due to coronary artery atherosclerosis and left ventricu…
Daryl Jabangardi Riley, a 42-year-old Aboriginal prisoner, died of ischaemic heart disease due to coronary artery atherosclerosis and left ventricular hypertrophy while playing pool in the recreation room at Alice Spring…
34y · Male·self-inflicted hanging
34-year-old Jordan Allen died by suicide on 1 February 2018 after absconding from Alice Springs Mental Health Unit during supervised cigarette leave. He was acutely psychotic with persecutory delusions related to methamp…
24y · Male·self-inflicted hanging
Linden Alan Kunoth, a 24-year-old Aboriginal man, died by suicide while on escorted leave from psychiatric care. He had been admitted with first-episode schizophrenia, presenting with florid psychosis and command halluci…
87y · Female·combined effects of ischaemic heart disease and chronic obstructive pulmonary di…
Epenesa Pahiva, 87-year-old resident with dementia at an aged care facility, suffered severe chemical burns from inappropriate bleach treatment prescribed by dermatologist Dr B.. The coroner found the treatment itself (h…
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
23y · Male·injuries sustained in fall from Tasman Bridge and/or drowning after submersion i…
A 23-year-old man with bipolar disorder, polysubstance dependence, and chronic self-harm died by jumping from the Tasman Bridge hours after psychiatric discharge. Despite two suicide attempts within 48 hours preceding as…
35y · Female·Unascertained
A 35-year-old grand multipara with multiple risk factors (BMI >35, smoking, grand multiparity, pregnancy-induced hypertension) presented at 40+4 weeks with absent foetal movements and was induced on Sunday evening. She e…
76y · Male·Hypothermia and multiorgan failure complicating compound left tibia and fibula f…
Leslie Roberts, a 76-year-old man with intellectual disability under DHHS care, died from hypothermia and multiorgan failure following a compound fracture of the left tibia and fibula sustained in a fall at home. He was …
57y · Female·multi-organ failure due to sepsis caused by streptococcus pneumoniae infection
Joanne Craig, a 57-year-old Aboriginal woman, presented to Katherine District Hospital on 24 January 2018 with fever, vomiting, and cough. She had streptococcus pneumoniae sepsis with elevated inflammatory markers from 1…
19y · Female·Multiple Injuries sustained in an Aviation Incident
Ms L, a 19-year-old student pilot, died in an aircraft accident during her first navigational solo flight. The Cessna 172 descended rapidly and impacted rising terrain. Investigation revealed she had engaged the autopilo…
37y · Male·blunt force injuries to the head and chest from jumping off an 8.65 metre roof
Daniel Bleaney, 37, experienced acute psychosis with command hallucinations while at sea and attempted suicide by jumping overboard. He was rescued and admitted involuntarily to Cowdy Ward, an open psychiatric ward, foll…
40y · Male·drowning
Graeme Bowerman drowned following the capsize of a recreational fishing boat in Marion Bay, Tasmania. The skipper, Mr Marriott, misjudged sea conditions and navigated into an active 3-metre swell in a surf break despite …
27y · Male·chest and abdominal injuries from single motorcycle crash
Jacob Wilson, aged 27, died from chest and abdominal injuries sustained in a motorcycle crash on 22 January 2018. He was travelling to a scheduled mental health appointment when he lost control of his motorcycle on a cur…
44y · Male·Hanging
Colin Wayne Blair, a 44-year-old Aboriginal man with a history of mental illness and substance use, died by hanging in the High Dependency Unit of Brisbane Correctional Centre on 13 November 2015. He was on hourly observ…
76y · Female·multisystem organ failure due to or as a consequence of ischaemic small intestin…
A 76-year-old woman presented to hospital with abdominal pain and was found on CT scan to have ischaemic colitis with signs of profound shock. The Consultant Surgeon decided on conservative management with fluid resuscit…
82y · Male·Complications associated with advanced chronic lung disease
Ivan Metcalfe, aged 82, died of complications from advanced chronic lung disease while in prison custody. He had multiple comorbidities including diabetes, ischaemic cardiovascular disease, and atrial fibrillation. He wa…
51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …
A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical less…
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