2,765 results
71y · Male·Drowning
A 71-year-old man drowned in Port Phillip Bay after his fishing vessel rapidly sank. Multiple factors contributed: an unsealed oval aperture in the engine well (originally designed for steering cable, later modified for …
17y · Male·Multi-organ failure with terminal fungal sepsis (Aspergillus) on a background of…
Ben Witham, a 17-year-old with acute lymphoblastic leukaemia, died from multi-organ failure with terminal fungal sepsis. The critical issue identified was a substantial delay in investigating acute severe abdominal pain …
32y · Male·hanging
A 32-year-old man with bipolar disorder and recent suicide attempt died by hanging in a closed psychiatric ward. He was admitted following overdose and suicidal ideation, deemed high-risk, and placed on standard half-hou…
65y · Male·Metastatic adenocarcinoma of unknown primary origin
Sen Hung Chen, a 65-year-old prisoner with hepatitis C cirrhosis, diabetes and hypertension, died from metastatic adenocarcinoma of unknown primary origin while in custody at Princess Alexandra Hospital Secure Unit. He p…
Male·Global hypoxic-ischaemic encephalopathy
Preston Paudel, born at 37 weeks gestation after meconium-stained labour with syntocinon augmentation, was delivered severely compromised with Apgar scores of 1-1-1 and died of hypoxic-ischaemic encephalopathy. Multiple …
14y · Male·complications of cerebral arterial gas embolism due to SCUBA incident
Reagan Milstein, a 14-year-old certified junior open water diver, died from complications of cerebral arterial gas embolism (CAGE) sustained during a recreational dive in Malaysia. He became unconscious during his second…
7y · Male·Joshua died due to a combination of physical entrapment of his head which occlud…
Joshua, a 7-year-old boy with spastic quadriplegia, epilepsy, and neurological impairment, died following entrapment of his head between hospital bed rails covered with bed bumpers while in hospital for gastroenteritis. …
15y · Female·compression of the neck
Sue Hui Wang, a 15-year-old student, died from compression of the neck between 16-19 September 2010 at her home in Balwyn, Victoria. The coroner found the exact circumstances of death unknown, unable to determine definit…
15y · Male·Cerebral ischaemia in a young man with a blocked ventricular peritoneal shunt an…
Vaughn Richard Rasmussen, a 15-year-old boy with congenital abnormalities and a ventricular-peritoneal (VP) shunt, died from cerebral ischaemia caused by acute blockage of his VP shunt on 17 November 2009. Between 12-16 …
19y · Male·Complications arising from hyperthermia, including total organ failure, rhabdomy…
Marcus Wilson, a 19-year-old roofing insulator, died from hyperthermia-induced organ failure, rhabdomyolysis and coagulopathy after working in a roof space during extreme heat (40°C+) without adequate hydration. He consu…
43y · Male·Hypoxic brain injury secondary to haemopericardium and tamponade complicating ru…
Mr Trevor McDonald, 43-year-old male, died from hypoxic brain injury following cardiac tamponade complicating coronary angioplasty. During elective PCI at Frankston Hospital, he sustained right coronary artery perforatio…
0y · Female·Peripartum hypoxia
Mia Davies died from peripartum hypoxia after a prolonged and poorly managed labour at Royal Brisbane and Women's Hospital. She had been diagnosed with multiple congenital anomalies (atrioventricular septal defect, oesop…
33y · Male·Aspiration pneumonia and hypoxic brain injury in a man consuming alcohol and met…
A 33-year-old man with alcohol dependence died from aspiration pneumonia and hypoxic brain injury after consuming approximately 40ml of methadone (not prescribed to him) combined with alcohol. The methadone was prescribe…
Three deaths with different primary causes: James Unicomb - acute toxicity due t…
Combined inquest into three deaths at Psyche South Clinic involving treatment failures: James Unicomb (22, 2005) from multi-drug overdose after naltrexone implant; Michael Poole (48, 2008) from ruptured aneurysm post-Rap…
0y · Female·Hypoxic-ischaemic encephalopathy arising from thrombosis in Blalock-Taussig shun…
Holly South, an 8-month-old with complex congenital heart disease requiring a Blalock-Taussig shunt, died of hypoxic-ischaemic encephalopathy from thrombosis in her shunt after presenting to hospital with vomiting and si…
37y · Male·Morphine toxicity from accidental overdose of crushed Kapanol (slow-release morp…
A 37-year-old male subject to home detention bail died from morphine toxicity due to accidental overdose of crushed Kapanol (slow-release morphine capsules). He had a long history of polysubstance abuse, encephalitis fro…
21y · Male·cardiac arrest caused by acute bilateral pneumonia
Stephen Moon, a 21-year-old with autism and intellectual disability, died following wisdom tooth extraction complicated by ventilator-acquired pneumonia. Although discharged early from ICU after 3 days, he developed bila…
29y · Male·hanging
Timothy Casey, 29, charged with murder, died by hanging in Port Phillip Prison on 28 March 2008, 12 days after arrival. His death resulted from systemic failures in psychiatric assessment and care. At Melbourne Assessmen…
41y · Male·Hanging
Timothy Casey, a 41-year-old remand prisoner with a history of major depressive disorder and drug/alcohol dependence, died by hanging in Port Phillip Prison in March 2008. The coroner identified multiple system failures:…
31y · Male·gunshot wounds to chest
Jason Chapman, a 31-year-old man with schizophrenia, was fatally shot by police on 13 October 2004 after behaving erratically and threatening, armed with a knife. The coroner found police acted lawfully in self-defence w…
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