2,762 results
29y · Male·Mixed drug toxicity, most significantly methamphetamine and buprenorphine, with …
Dion Moore, a 29-year-old Aboriginal man, died on 5–6 January 2019 from mixed drug toxicity (methamphetamine and buprenorphine), with heat and dehydration as significant contributing factors. After running out of fuel wi…
34y · Male·Gunshot injuries to chest and left shoulder
Joseph Abela, a 34-year-old with chronic paranoid schizophrenia and polysubstance use, died from gunshot wounds inflicted by police during a mental health welfare check on 25 October 2021. Critical clinical failures prec…
54y · Male·quetiapine toxicity in a man with ischaemic heart disease
Shane Pappas, a 54-year-old man with ischaemic heart disease, died from quetiapine toxicity after deliberately overdosing on multiple medications on 29 June 2021. He had experienced a recent relationship breakdown and pr…
41y · Male·sympathomimetic syndrome
Andrew Berry, a 41-year-old man with a long history of methamphetamine use and criminal offending, died of sympathomimetic syndrome following arrest by police on 14 January 2020. He was arrested after attempting to break…
36y · Male·Neck compression secondary to hanging
A 36-year-old man with a history of depression, anxiety, and alcohol dependence died by suicide during the COVID-19 pandemic following job loss. He presented to a psychotherapist with suicidal ideation, multiple risk fac…
34y · Female·multiple drug toxicity
Katherine Alexander, a 34-year-old woman with chronic suicidality and complex mental health conditions including bipolar II disorder, borderline personality disorder, and PTSD, died from multiple drug toxicity on 7-8 Feb…
73y · Female·sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopi…
A 73-year-old woman died from sepsis due to breakdown of oesophageal/gastric anastomosis following laparoscopic revision of gastric bypass surgery. She had complex medical history with multiple post-operative complicatio…
18y · Male·Sodium nitrite toxicity
Nathan Greenwood, an 18-year-old with a history of anxiety and depression managed in primary care, died from sodium nitrite toxicity after intentionally consuming 30 grams of the substance. He had been under care at his …
85y · Male·head and neck injuries sustained when operating a bulldozer that rolled down a g…
An 85-year-old experienced heavy machinery operator died from head and neck injuries sustained when a Komatsu bulldozer he was operating rolled approximately 80 metres down a gully while reversing near the soft edge of a…
31y · Female·Pressure applied to neck (asphyxia); not ascertained due to advanced post-mortem…
A 31-year-old First Nations woman was killed by her partner during intimate partner violence. She was pregnant at the time of death. Despite multiple contacts with police, court services, employment agencies, and domesti…
54y · Male·metastatic lung cancer with terminal palliative care
Jason Anthony Thompson, a 54-year-old long-term prisoner at Casuarina Prison, died from metastatic lung cancer. He collapsed on 17 February 2023 with suspected opioid overdose but was not transferred to hospital for appr…
76y · Male·metastatic prostate cancer with terminal palliative care
Kevin John Keath, aged 76, died from metastatic prostate cancer while serving a life sentence at Casuarina Prison. He received holistic, compassionate, and appropriate healthcare throughout his incarceration, including r…
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
57y · Male·multiple injuries sustained in helicopter crash
Roger Corbin, a highly skilled and experienced helicopter pilot and instructor, died in a crash during emergency training on 7 November 2017. While instructing student John Osborne in a simulated hydraulic failure landin…
41y · Male·complications in association with effects of fire, with terminal palliative care
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
46y · Male·acute neck compression due to hanging
Simon David Muller, aged 46, died by hanging at his home on 10 June 2021 while on home detention bail. He had been unemployed since 2017 and had no known previous mental health diagnoses or suicide attempts. Drug testing…
92y · Male·unascertained
A 92-year-old man with advanced dementia died in aged care following an unwitnessed fall on 3 December 2021. He deteriorated rapidly after a second fall at 11:45pm and died shortly after. The precise cause of death remai…
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