Unknown·Carbon monoxide poisoning and burns (or burns only in one case), accidentally su…
Seven children and teenagers died in the Luna Park Ghost Train fire on 9 June 1979 when the timber-framed building became engulfed in dense smoke and flames. The fire likely originated from a carelessly discarded cigaret…
47y · Female·ligature compression of the neck (hanging)
A 47-year-old woman remanded in custody at Melaleuca Women's Prison died by ligature compression of the neck (hanging) on 13 August 2020. Ms Davis had significant history of substance use, mental health issues, and prior…
85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)
Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …
15y · Male·Hypoxic ischaemic brain injury, due to hanging
A 15-year-old boy died from hypoxic-ischaemic brain injury following a hanging attempt on 10 November 2004. The death occurred hours after his parents were informed by the school that he had been absent for seven consecu…
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
51y · Male·Complications of chronic ethanol use
EH was a 51-year-old man with chronic alcohol dependence, liver cirrhosis, and recent hip fracture complications who died at home on 1 November 2022 whilst waiting for an ambulance. He had self-discharged from St Vincent…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …
56y · Female·Bronchial asthma and emphysema
A 56-year-old woman with long-standing schizophrenia, COPD, emphysema, and heavy smoking died during overnight leave from psychiatric hospitalisation. She was granted leave to check on her cat at her remote home on 24 Ma…
35y · Male·drowning (immersion)
Damien Mills, a 35-year-old mortgage broker, drowned in the Indian Ocean after falling off a charter boat returning from Rottnest Island on 31 October 2014. While intoxicated, he was likely knocked overboard during rough…
69y · Female·Intra-abdominal sepsis and shock with multi-organ failure following intestinal p…
A 69-year-old woman died from intra-abdominal sepsis and multi-organ failure following a perforated caecum that occurred after lumbar spine surgery. Post-operatively, she developed abdominal distension and pain initially…
44y · Male·Ligature compression of the neck and methylamphetamine effect
Anthony William Kuster, a 44-year-old man, died from ligature compression of the neck combined with methylamphetamine toxicity. He applied a tourniquet around his neck while heavily intoxicated with methylamphetamine aft…
57y · Female·Multiple penetrating (stab) injuries to the body and neck
Satwant Kaur, aged 57, was murdered by her stepson in her home on 5 December 2013 after he made multiple threats to kill her while in custody. Critical failures in intelligence sharing between the Department of Correctiv…
18y · Female·Acute Alcohol Toxicity with Early Pneumonia and Aspiration
An 18-year-old female, a naive drinker, consumed approximately 19-21 standard drinks over a few hours at her birthday party, including vodka cruisers, a full-strength Midori drinking game, and Polmos (95% alcohol). She r…
22y · Female·Unable to determine - open finding
Petronella Albert, a 22-year-old Aboriginal woman from Broome, disappeared in late April or early May 1999 and is presumed deceased. The coronial inquest, conducted in 2017, established her death beyond reasonable doubt …
41y · Male·unknown
Dean Anthony Pollard was a 41-year-old man with a long history of schizophrenia and amphetamine-induced psychotic disorder who disappeared in May-June 2010 and is presumed dead. He had multiple psychiatric admissions bet…
41y · Male·atropine toxicity
A 41-year-old man with schizoaffective disorder, intellectual disability and sexual offending history died from atropine toxicity after ingesting 6-8ml of atropine liquid prescribed for hyper-salivation. He had been disc…
22y · Male·drowning secondary to incapacitation from air embolism
A 22-year-old skilled and experienced pearl shell drift diver with over 600 logged dives died from drowning secondary to air embolism and cerebral arterial gas embolism while diving for Paspaley Pearling Company off Broo…
0y · Male·severe hypoxic ischaemic encephalopathy secondary to uterine rupture
Baby AM died from severe hypoxic ischaemic encephalopathy secondary to uterine rupture during a planned home vaginal birth after caesarean (VBAC). The mother, Ms M, was 40 weeks and 5 days pregnant, attended by a private…
74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …
Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…
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