29y · Male·Ketoacidosis as a consequence of diabetes mellitus (Type 1)
Steven Thelander, aged 29, died from ketoacidosis due to poorly controlled Type 1 diabetes while in residential disability support care at Multicap. He had cerebral palsy with severe intellectual impairment and epilepsy …
43y · Male·Bilateral pulmonary thrombo-emboli; contributory factors included obesity, coron…
Paul Harris, a 43-year-old Aboriginal man, died from bilateral pulmonary emboli while hospitalized at Hay District Hospital. He presented in September 2019 with pneumonia and Q fever (occupational exposure from kangaroo …
27y · Female·Cardiac arrhythmia (first confirmed as ventricular fibrillation) of unascertaine…
A 27-year-old Aboriginal woman suffered sudden cardiac arrhythmia (ventricular fibrillation) immediately after recording video evidence of a suspected breach of her protective apprehended personal violence order (APVO). …
14y · Female·ligature compression of the neck (hanging); suicide
A 14-year-old girl in state care (Child RK) died by suicide on 20 April 2022. She had complex presentations stemming from early childhood trauma, including attachment difficulties, emotional dysregulation, self-harm, sui…
55y · Female·acute necrotising bronchopneumonia
MQ, 55, died of acute necrotising bronchopneumonia on 2-3 March 2023. She had developed community-acquired pneumonia from 21 February 2023, presenting initially with referred shoulder pain (later recognised as diaphragma…
61y · Male·Right lower lobe pneumonia
Graeme William Kenny, a 61-year-old man with trisomy 21 and dementia, died from right lower lobe pneumonia on 25 December 2024 at Monash Medical Centre following palliative care. He developed upper respiratory symptoms o…
60y · Male·Neck compression secondary to hanging
A 60-year-old man with Type 2 diabetes and low mood died by hanging within 24 hours of being interviewed by police regarding child sexual abuse allegations. While police identified that suspects are at heightened suicide…
54y · Female·mixed drug toxicity (methadone and diazepam)
A 54-year-old woman with long-standing opioid use disorder died from mixed methadone and diazepam toxicity. She had tripled her methadone dose by injecting additional takeaway doses alongside her prescribed pharmacy dose…
65y · Female·Combined effects of acute pneumonia, pancreatitis, urinary tract infection, and …
A 65-year-old woman with chronic alcohol use disorder, multiple comorbidities, and progressive functional decline died from combined effects of pneumonia, pancreatitis, urinary tract infection, and severe pressure ulcers…
43y · Male·methadone toxicity
Frank Coleman, a 43-year-old First Nations man, died of methadone toxicity after being supplied diverted methadone by another inmate while imprisoned at Long Bay Correctional Complex. Mr Coleman had repeatedly requested …
39y · Female·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest due to methadon…
A 39-year-old woman with opioid dependency died from methadone toxicity following cardiac arrest. She had been prescribed up to six take-away doses of 120mg methadone per week by her GP under Queensland's Opioid Treatmen…
27y · Female·Hanging
Ms YPM, a 27-year-old woman with a long history of borderline personality traits, depression, anxiety and eating disorder, died by hanging on 17 May 2020. In the preceding two weeks, she presented to Alfred Hospital foll…
31y · Male·Hanging
31-year-old male with borderline personality disorder, alcohol use disorder, and history of self-harm died by hanging. He had multiple presentations to emergency services and mental health services from March to July 202…
42y · Female·Haemothorax and pneumonia in the setting of acute and chronic chest injuries and…
Narelle Simmons, 42, died from haemothorax and pneumonia secondary to rib fractures, with contributing factors of hepatic cirrhosis, chronic alcoholism, and multiple drugs (methadone, methylamphetamine, diazepam, sertral…
3y · Female·Streptococcus pyogenes septicaemia
A three-year-old girl with Down syndrome died from Group A Streptococcus septicaemia after a 10-day illness. She presented four times to hospital (ED and rapid review clinic) over three days with fever, rash, and diarrho…
41y · Male·ligature compression of the neck (hanging)
Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been r…
Male·unascertained
Nicholas Pavlidis disappeared in October 2015 after last being seen alive on 14 October 2015. His abandoned vehicle was reported to police on 24 October 2015 in Yanchep bushland, but initial police response treated it as…
74y · Male·Sepsis secondary to infected pressure wounds (necrotising fasciitis) in a man wi…
A 74-year-old man with multiple comorbidities (diabetes, obesity, respiratory failure, mental health conditions) died from sepsis secondary to necrotising fasciitis of pressure wounds developed while in aged care. Key cl…
26y · Female·Multiple stab wounds
ZSQ, a 26-year-old woman, was fatally stabbed by her intimate partner MJD in April 2020 after a relationship marked by escalating family violence. Critical clinical and systemic lessons include: (1) Recognition of intima…
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
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