2,765 results
59y · Male·Ruptured atherosclerotic abdominal aortic aneurysm (operated)
A 59-year-old man with a non-ruptured 8cm infrarenal abdominal aortic aneurysm (AAA) presenting with acute back pain was transferred from Bendigo to Royal Melbourne Hospital at 2.13am on 22 April 2008. Despite appropriat…
15y · Male·asphyxiation by hanging
Cody Jackson, aged 15, died by asphyxiation from hanging in March 2009. He had a troubled family background with exposure to violence, substance abuse, and criminal activity. Cody was involved with multiple services incl…
69y · Male·subarachnoid haemorrhage with contributing cardiomegaly
A 69-year-old man with hypertension presented with sudden onset severe headache, photophobia, nausea and neck stiffness—classic features of subarachnoid haemorrhage. A CT angiogram identified a 6mm aneurysm on the anteri…
45y · Male·subdural haemorrhage sustained in a fall
Benjamin Ware, an intoxicated 45-year-old man, was taken by police to a diversionary centre in Cairns. He vomited several times during the evening and was monitored regularly by staff. The next morning, other clients wok…
42y · Female·Head injury due to ejection of a section of steel pipe from slasher
A pedestrian was fatally struck by a metal pipe ejected from a slasher operating on a vacant urban block. The coroner found that while the incident occurred in an urban setting with foreseeable pedestrian presence, criti…
46y · Male·metastatic malignant melanoma
A 46-year-old man with metastatic malignant melanoma died in custody at a hospice. He was extradited from New South Wales to South Australia in April 2009 while undergoing cancer treatment. There was an 8-week delay befo…
5y · Male·Brainstem encephalitis (viral)
Rolden Ablis, aged 5, presented to Frankston Hospital Emergency Department with fever, vomiting, and dehydration on 10 December 2007. He was diagnosed with gastroenteritis and admitted for fluid resuscitation. Despite cl…
35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…
Justin Fraser, a 35-year-old male with first-episode psychosis, died in restraint at Frankston Hospital psychiatric ward on 26 October 2007. He was found attempting suicide by hanging, became agitated and threatening, le…
35y · Male·Sudden death during restraint in an agitated obese man with coronary artery athe…
Justin Fraser, a 35-year-old man with first-episode psychosis admitted to Frankston Hospital psychiatric unit, was found attempting suicide by hanging and subsequently became agitated. Security and AMT staff physically r…
17y · Female·Acute Methylenedioxymethylamphetamine (MDMA) toxicity
Gemma Thoms, a 17-year-old girl, died from acute MDMA toxicity after consuming three ecstasy tablets at the Big Day Out music festival on 1 February 2009. She collapsed and died on 2 February 2009. Key clinical lessons: …
26y · Female·intentionally inflicted gunshot wounds to the head
This complex triple-inquest into the deaths of two women in 1991 reveals systemic investigative failures and challenges the original murder-suicide finding. Julie-Anne Leahy and Vicki Arnold died from gunshot wounds on 2…
33y · Male·Cardio-respiratory arrest in the setting of prone restraint of an agitated obese…
A 33-year-old man with schizophrenia and a forensic history suffered cardio-respiratory arrest during prone restraint in a busy emergency department after his mental health community treatment order was revoked. He was a…
37y · Female·Unascertained; possibly sudden cardiac arrhythmia
Raelene Syddall, aged 37, died unexpectedly at home on 8 January 2012 after taking prescribed bowel preparation (Picolax) for a colonoscopy. She ingested the preparation according to instructions but appears to have over…
93y · Male·Intracranial haemorrhage in the setting of over-warfarinisation
A 93-year-old man on warfarin for atrial fibrillation sustained a head strike in a fall at residential aged care. Initial assessment by ambulance was appropriate and he was not transferred. Over subsequent days, neurolog…
32y · Male·Gunshot wound to head (self-inflicted)
Shane Andrew Robinson, a 32-year-old registered child sex offender and parolee with a long violent criminal history and substance abuse problems, died by self-inflicted gunshot wound while evading police during a siege a…
58y · Male·metastatic multiple myeloma
Harry Richard Nylander, aged 58, died in prison custody from metastatic multiple myeloma on 25 January 2008. An inquest was mandatory due to his custodial status. Expert medical review by a senior medical oncologist conc…
58y · Male·metastatic adenocarcinomatosis with unknown primary source
A 58-year-old prisoner died of metastatic adenocarcinoma with unknown primary. In September 2006, significantly abnormal liver enzymes (GGT 2093) and hyperglycemia were detected. A December 2006 ultrasound identified an …
83y · Male·Aspiration pneumonia
An 83-year-old man with stroke, dementia, dysphagia, and multiple comorbidities developed aspiration pneumonia while in aged care. On 1 May 2008, he presented with acute swallowing difficulty and was examined by his GP w…
Unknown·Ms Fensom: influenza A (H1N1 2009, pandemic swine flu) with myocarditis causing …
Two deaths from H1N1 influenza in 2009. Ms Fensom (41) died from myocarditis complicating swine flu after inadequate recognition and management of persistent hypotension at Millicent Hospital. Her condition required esca…
42y · Male·ischaemic heart disease due to coronary atherosclerosis
Jonathon Candy, aged 42, died from acute coronary syndrome one day after inappropriate discharge from Queen Elizabeth Hospital ED. He presented with recurrent chest pain on exertion (gym evening of 18 May, workplace morn…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.