2,762 results
55y · Male·Complications of liver cirrhosis and hepatocellular carcinoma in a man with mult…
Robert Exell, a 55-year-old Aboriginal man, died from complications of liver cirrhosis and hepatocellular carcinoma while in custody. He had chronic hepatitis C and alcohol-related liver disease since at least 2012. Key …
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
35y · Male·multi-drug toxicity
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…
68y · Female·Sepsis (palliated)
Ms Eddolls, a 68-year-old woman with intellectual disability and complex medical conditions, died from sepsis secondary to pressure ulcers while in specialist disability accommodation. She developed sacral and heel press…
52y · Female·Spinal injuries sustained in falls in a woman with multiple medical comorbiditie…
Caroline Monique Hall, a 52-year-old woman with intellectual disability, epilepsy, schizophrenia, and multiple comorbidities living in supported disability accommodation, died from spinal injuries sustained in falls. She…
53y · Male·Cervical spine distraction and hanging
A 53-year-old man with chronic treatment-resistant depression and chronic suicidality was admitted to Northern Hospital following a serious suicide attempt. He was assessed as high-risk but discharged after 19 days with …
16y · Male·Complications of acute alcohol intoxication
A 16-year-old male died from complications of acute alcohol intoxication after consuming a dangerous quantity of alcohol (estimated blood alcohol content 0.34-0.4 g/100mL at midnight) at a family Christmas gathering. He …
24y · Male·Hypoxic Ischaemic Encephalopathy due to hanging
Jayke Aleckson, 24, died by hanging in a non-BDRP compliant prison health cell while on remand at Marngoneet Correctional Centre in October 2018. Key clinical lessons: (1) Multiple unmet requests for antidepressant medic…
59y · Male·Hanging
Terry Grady, a 59-year-old man with a history of alcohol dependence, depression, and chronic pain, died by suicide in custody at Parklea Correctional Facility on 8-9 August 2019. He was bail-refused for domestic violence…
79y · Male·Respiratory failure due to haemothorax and hospital-acquired pneumonia due to mu…
A 79-year-old man with extensive comorbidities died following multiple falls in residential aged care. He was identified as high falls risk on admission but experienced inadequate falls prevention after a second fall on …
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
58y · Male·Hanging
Zoran Alic, a 58-year-old Serbian-born man detained at Marngoneet Correctional Centre on family violence charges, died by hanging on 29 April 2019. He was referred for psychiatric assessment on 28 March 2019 after report…
1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…
A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…
37y · Male·unascertained
Cyril Levitsky disappeared from Callan Park Hospital in 1970 while under treatment for schizophrenia. He was never found, though an unidentified male body discovered nearby in December 1970 may have been him. Despite ext…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
25y · Male·Gunshot injury to the head
SK, a 25-year-old man with ADHD, borderline personality disorder, PTSD, depression and anxiety, died from a self-inflicted gunshot wound while handling an unregistered revolver under the influence of amphetamines, cannab…
Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…
This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
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