2,762 results
66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, …
Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellen…
11y · Male·unascertained
An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…
85y · Female·Complications of a left ankle fracture (operated)
An 85-year-old woman with multiple comorbidities (diabetes, ischaemic heart disease, hypertension, prior stroke) sustained a left ankle fracture requiring surgical repair. A significant delay occurred in removing her pla…
50y · Female·Multiple stab wounds to the abdomen and chest
Michelle Michell, a 50-year-old woman, was stabbed to death by her estranged husband Neville in a premeditated domestic violence homicide on 30 June 2021. Critical lessons include: (1) police failed to recognise escalati…
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…
6y · Unknown·methadone toxicity
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
A 76-year-old man with a history of unprovoked DVT/PE on lifelong warfarin was admitted with COVID-19 and developed a bleeding duodenal ulcer requiring endoscopic treatment. Warfarin was ceased to prevent further bleedin…
67y · Female·Pulmonary thromboembolism arising from deep vein thrombosis of the left leg
Kathleen Mary Savage, a 67-year-old woman with profound intellectual disability, died from pulmonary thromboembolism and deep vein thrombosis following a 13-day hospital admission for constipation and sepsis. She collaps…
58y · Female·Unascertained
Colleen Mary South, aged 58, was found deceased on 8 August 2022 under a tree in a remote rural paddock in Bunguluke, Victoria, approximately 1.5 kilometres from her abandoned vehicle. She had a significant psychiatric h…
41y · Female·ligature compression of the neck (hanging)
Petya, a 41-year-old Bulgarian-born woman, died by ligature compression of the neck while an involuntary psychiatric patient at Bentley Health Service Ward 6 on 16 December 2020. She had been admitted following acute psy…
83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…
Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling un…
45y · Female·Neck compression secondary to hanging
Claire Louise Carroll, 45, died by hanging while experiencing severe untreated psychotic symptoms including auditory hallucinations, paranoid delusions, and persecutory ideation. She had complex mental health diagnoses (…
systemic inquiry into 2019-2020 NSW bushfire season deaths - no single death exa…
Volume 2 of a comprehensive coronial inquiry into systemic issues arising from the 2019-2020 NSW bushfire season. The State Coroner examined 41 fires through Stage 1 hearings and conducted Stage 2 representative case stu…
Unknown·Thermal injury and burns from bushfire exposure; smoke inhalation
The 2019/2020 NSW bushfire season was catastrophic, with 25 deaths investigated by the State Coroner through inquests and 41 fires through inquiries. Over 5.52 million hectares burned, destroying 2,476 homes and damaging…
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
51y · Female·Unable to determine cause of death
Marion Barter (51) disappeared in 1997 after changing her identity to Florabella Natalia Marion Remakel. She sold her house, resigned from her teaching position, and travelled to England on 22 June 1997, returning on 2 A…
26y · Male·Craniocervical injuries following a train collision (pedestrian)
Sidarthan Gajaharan, a 26-year-old with treatment-resistant schizophrenia, died by suicide after being struck by a train while on unescorted ground leave from an involuntary mental health admission. He had been hospitali…
31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…
A 31-year-old man with schizoaffective disorder and substance use was admitted involuntarily to the Kiloh Centre after presenting in acute psychosis with suicidal ideation on 1 April 2017. His psychotic symptoms rapidly …
39y · Female·Sudden cardiac arrhythmia following the administration of Kambo frog toxin
Natasha Lechner, a 39-year-old woman with chronic pain from degenerative disc disease, died from sudden cardiac arrhythmia triggered by Kambo frog toxin administration during a ceremony. She had completed Kambo practitio…
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