2,762 results
36y · Male·Hypoxic Ischaemic Encephalopathy
Brenden Montgomery, aged 36, died from hypoxic ischaemic encephalopathy after hanging himself on 30 December 2019 while police were present outside his home. He had a long-standing history of depression and anxiety, prev…
29y · Male·Hanging
ZH, a 29-year-old man serving a 9-year sentence for drug supply, died by hanging in his minimum-security cell at Parklea Correctional Centre on 11 August 2021. The coroner found his death was self-inflicted. Key clinical…
73y · Male·Infectious Exacerbation of Chronic Obstructive Airways Disease with the Contribu…
Mr H, a 73-year-old man with chronic obstructive airways disease and Lewy body dementia, was admitted to hospital on 6 January 2021 following a psychiatric incident and was found to have pneumonia and severe infection. H…
13y · Male·Hanging
Oliver Cronin, a 13-year-old boy, died by hanging at Royal Children's Hospital after a year-long escalation of gaming addiction and behavioural problems. He had become increasingly dependent on gaming platforms (Roblox, …
51y · Female·Multiple injuries sustained from a fall from the top floor of a multi-storey car…
Justine Painter, aged 51, died from multiple injuries sustained jumping from a multi-storey carpark while an inpatient at Royal Perth Hospital (RPH). She had severe treatment-resistant schizoaffective disorder, command h…
17y · Female·Hanging
Charli Powell, 17, died by hanging at Freebody Oval on 11 February 2019 during an abusive relationship with Rohan Rosewarne. The coroner found her death was intentionally self-inflicted but occurred in the context of sig…
Male·Fentanyl toxicity, with aspiration pneumonia as a significant contributing condi…
A man (ZA) died from fentanyl toxicity in custody at Shortland Correctional Centre after his cellmate, who had brought fentanyl into the prison by concealing it in his rectum, shared it with him. Both men snorted the pow…
72y · Male·Diffuse large B cell lymphoma
Douglas Stott, a 72-year-old prisoner with diffuse large B cell lymphoma, died of natural causes in hospital on 7 January 2021. He had been receiving telehealth oncology consultations while incarcerated but refused in-pe…
3y · Unknown·Unascertained - natural causes; evidence of aspiration pneumonia, hypoxic-ischae…
Baby R, born at 38 weeks gestation to a mother with previous pregnancy losses, was small-for-gestational-age (SGA, 10th centile). The mother was appropriately excluded from the hospital-supported home birth program due t…
44y · Male·Unascertained
Mark Skidmore, a 44-year-old man, died in Port Phillip Prison on 14 February 2017. Post-mortem examination revealed multiple prescribed drugs (methadone, mirtazapine, pregabalin) and unprescribed drugs (clonazepam, trama…
44y · Female·Hanging
Kerry-Ellen Knight, aged 44, died by suicide in custody at Silverwater Women's Correctional Centre on 5 March 2021 after only 6 days in custody. She was in COVID-19 quarantine in an old-style cell with prominent hanging …
66y · Male·Ruptured abdominal aortic aneurysm
A 66-year-old man presented to the Emergency Department with left-sided abdominal pain on 14 July 2021. After waiting over 6 hours in a crowded ED with restricted access to treatment spaces, he left without medical asses…
22y · Female·cardiac arrest of uncertain cause noting the existence of drug toxicity; the dru…
Faithe Baxter, aged 22, died from cardiac arrest due to methamphetamine toxicity after using multiple drugs including methamphetamine, benzodiazepines, opioids and nitrous oxide. She became unconscious in a car overnight…
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
2y · Unknown·Drowning
Child C, a 2-year-old living on a rural property in Victoria, drowned in an unsupervised dam. Child Protection had received six reports over 2.5 years documenting neglect, poor supervision, and cumulative harm, but close…
36y · Male·Cannot be determined
CD, aged 36, disappeared on 17 June 2019 after exhibiting significant mental health deterioration, recent suicidal ideation, paranoia, alcohol abuse, and relationship breakdown. The coroner found sufficient evidence that…
81y · Male·cardiac arrest following neck compression due to hanging
An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
Ian Fackender, aged 47, died from gunshot wounds during a Community Treatment Order breach enforcement operation in his home. He had severe, treatment-resistant schizophrenia and was acutely psychotic during the incident…
41y · Female·neck compression
Kim Lynch, 41, died from neck compression between 12-14 February 2016. She was in a relationship with LM, who had paranoid schizophrenia, substance abuse issues, and a history of violence. Following a family violence inc…
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