84y · Male·The available evidence does not allow for any finding to be made as to the cause…
An 84-year-old man with Alzheimer's dementia and a history of wandering left his home on 15 September 2017 and was never found alive. The coroner determined he is deceased, likely died within days of going missing in bus…
30y · Male·Head and neck injury in a motorcycle incident
A 30-year-old male motorcyclist died from head and neck injuries sustained in a motorcycle incident on the Western Ring Road on-ramp on 26 July 2018. The coroner found that a water leak from a fire hydrant on VicRoads-ow…
18y · Male·drowning in a motor vehicle accident
MK, 18 years old, died by drowning after his car entered Isabella Pond following a motor vehicle accident. Witnesses observed him inhaling from a balloon-shaped object while driving through a roundabout. A large nitrous …
39y · Male·Hanging
A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm …
60y · Male·Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with…
A 60-year-old man remanded in custody died from pulmonary tuberculosis complicated by severe COPD. Key clinical issues included: delayed diagnosis (TB not suspected at intake despite respiratory symptoms), patient's refu…
78y · Female·Hypoxic ischaemic encephalopathy as a result of obstruction of airway caused by …
A 78-year-old woman died from hypoxic ischaemic encephalopathy following an acute post-surgical arterial bleed that obstructed her airway after hemithyroidectomy. The bleeding complication occurred when she coughed after…
22y · Male·Airway obstruction due to laryngeal abscess and laryngeal chondronecrosis due to…
Kyle Gallagher, age 22, died from airway obstruction due to laryngeal abscess and chondronecrosis following a motorcycle accident. A CT scan on 13 July 2023 showed a critically narrowed (3mm) subglottic airway with suspe…
Male·Hemant Chadha: acute on chronic pneumonia (mycoplasma pneumoniae). Sachintha Bat…
Two young men died after repeated ED presentations were not appropriately managed. Hemant Chadha (38) died of acute pneumonia complicated by possible neurological involvement after being discharged from Lyell McEwin Hosp…
52y · Male·Complications of chronic cardiac failure in the setting of ischaemic heart disea…
Sacha Timothee Louis Lefebvre, aged 52, died from complications of chronic cardiac failure with ischaemic heart disease and chronic anaemia whilst sleeping rough at Hawthorn Library. He had multiple chronic conditions in…
1y · Male·Complications of acute lymphoblastic leukaemia
A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…
35y · Male·self-inflicted gunshot wound to the head
Ralph Donald, aged 35, died by suicide after attempting to kill his ex-partner Eileen Gibbons on 3 October 2023 in Milner, NT. The death occurred in context of escalating coercive control including verbal abuse, property…
71y · Male·Multiple injuries sustained in a cycling accident caused by impact with a tree b…
Paul Storey, a 71-year-old active cyclist, died from multiple injuries sustained when his head struck a large tree branch hanging across a bicycle path on Black Mountain Peninsula, ACT. A public report of the hazardous t…
41y · Female·Multiple injuries from assault
A 41-year-old woman with physical disability and stable mental health was killed by her adult son through severe blunt force trauma including extensive rib fractures causing flail chest, pneumohaemothorax, liver lacerati…
30y · Female·Head injuries sustained in a motor vehicle incident (passenger)
A 30-year-old female passenger died from head injuries sustained in a multi-vehicle collision on the Princes Highway when a truck failed to stop in time. The collision resulted from a 'looming collision'—where the truck …
44y · Female·Mixed alcohol and drug toxicity (tapentadol, diazepam, mirtazapine, amitriptylin…
Aisha Natasha Khan, 44, died from mixed alcohol and drug toxicity following an intentional polypharmacy overdose with alcohol consumption. She had a history of depression, alcohol use disorder, chronic pain, and two prio…
42y · Female·hypovolaemic shock due to an acute ruptured subcapsular splenic haematoma in the…
Eve Brown, a 42-year-old Aboriginal woman, died of hypovolaemic shock from a ruptured splenic haematoma in the context of urosepsis at a regional hospital. She presented with UTI symptoms and was admitted to Lightning Ri…
1y · Female·Obstructive sleep apnoea occurring in the context of significant, unrecognised h…
Serena Lee, born 31 October 2021, died at 2 months from obstructive sleep apnoea in the context of severe, unrecognised hypoglycaemia associated with intrauterine growth restriction (IUGR). She was discharged from Campbe…
31y · Male·metastatic alveolar soft part sarcoma
31-year-old man serving a custodial sentence died of metastatic alveolar soft part sarcoma on 25 January 2022. Diagnosed April 2020, the ultra-rare cancer (1 in 10 million incidence) had already metastasised at discovery…
56y · Male·complications of viral hepatitis related advanced-chronic liver disease (medical…
Russell Graham Penny, a 56-year-old Aboriginal man, died from complications of advanced chronic liver disease with hepatocellular carcinoma while imprisoned at Casuarina Prison. He had a long history of hepatitis C and c…
58y · Male·acute myocardial infarction caused by ischaemic heart disease
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…
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