20y · Male·ruptured heart and aorta due to fall from a height
A 20-year-old male with newly diagnosed disorganised schizophrenia died by suicide from a fall from the 5th floor of a hospital maternity building while detained under the Mental Health Act. He had been admitted to the C…
34y · Female·hypoxic brain damage complicating fresh water drowning
Alice Louise McTye, a 34-year-old woman with severe intellectual disability and epilepsy, died from hypoxic brain damage following fresh water drowning in a bath at a disability services residence. The coroner found she …
0y · Female·premature delivery; extreme prematurity
A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…
42y · Female·salt water drowning
Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…
73y · Male·dehydration and hyperthermia
A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…
Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…
30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin
Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…
24y · Male·plastic bag asphyxiation
Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…
31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…
Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …
17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…
Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…
Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…
Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …
12y · Female·Head injury caused by high-velocity steel fragment missile, approximately 999 gr…
Katie Bender, aged 12, was struck fatally in the head by a 999-gram steel fragment while watching the controlled implosion of Royal Canberra Hospital on 13 July 1997. The fragment travelled 430 metres in 3.1 seconds at 1…
14y · Male·Loss of blood arising from incised wound to the left arm (cubital fossa)
A 14-year-old Aboriginal petrol sniffer brought to a remote outstation (Ilpurla) without pre-arrangement died from massive haemorrhage following a self-inflicted laceration to his arm. Clinical lessons: petrol sniffers i…
0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…
Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…
36y · Male·Toxic overdose of Clozapine (anti-psychotic drug), self-administered, with termi…
Brian Duff, a 36-year-old with severe chronic schizophrenia, died from Clozapine toxicity (pulmonary oedema and cardiac arrest) on 14-15 February 1997. He was subject to a Community Treatment Order and under case managem…
Male·smoke inhalation and burns
On 8 April 1996, a fire at Kew Residential Services killed nine intellectually disabled residents (aged 31–61) from smoke inhalation and burns when a resident used a cigarette lighter to ignite bedding. The coronial inqu…
21y · Male·Suffocation from hanging
Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…
69y · Female·Asthma
June Sylvia Long, aged 69, suffered an asthma attack at home on 28 June 1994 and was transported to Alfred Hospital. She deteriorated overnight in the hospital's Respiratory Ward despite initial improvement in Emergency …
3y · Male·cerebral oedema which caused coning at the base of the brain, caused by post-ope…
A 3-year-old boy died from cerebral oedema caused by post-operative hyponatraemia following scoliosis correction surgery. The operation was successful, but severe hyponatraemia developed in the early hours of 24 April 19…
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