2,762 results
33y · Female·hanging
A 33-year-old woman with major depressive disorder and a history of suicide attempts died by hanging five days after discharge from hospital following a carbon monoxide poisoning attempt. The coroner found that discharge…
49y · Male·Global cerebral hypoxia due to cardiac arrest and drowning, with bilateral bronc…
Mark Murphy, an experienced diver with 657 logged dives, died during an occupational diving course when his full face mask became accidentally dislodged underwater, resulting in sudden cold-water exposure. This triggered…
0y · Male·Acute traumatic head injury (non-accidental)
A 7-month-old child died from acute traumatic head injury sustained from non-accidental blunt force. Clinical lessons include: medical staff should strongly reinforce urgent referrals (the child had a critical GP referra…
13y · Male·Effects of fire due to motor vehicle collision
A 13-year-old boy in youth residential care, grieving his mother's death one year prior, forcibly entered the facility office with a companion and stole a carer's car keys. They drove to their hometown, lost control of t…
Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …
Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…
34y · Female·Multiple injuries sustained in a motor vehicle incident (pedestrian), in circums…
Melissa Gaultier, 34 years old, was discharged from Latrobe Regional Hospital's psychiatric ward (Flynn Unit) less than 24 hours after admission on 13 April 2017, despite comprehensive warnings from Monash Health that sh…
49y · Female·Doreen Langham: combination of spleen injury and effects of fire; Gary Hely: eff…
Doreen Langham was killed by her intimate partner Gary Hely in an intimate partner homicide-suicide on 22 February 2021 in Queensland. The death was preceded by extensive domestic violence including physical assaults, co…
44y · Male·Heroin toxicity
A 44-year-old man with a 24-year history of opioid addiction died from heroin toxicity two days after release from prison on a Community Corrections Order. He had been on opioid replacement therapy (Suboxone) but discont…
70y · Male·hypovolaemic shock due to the consequences of fractured femur
Thomas Fulcher, a 70-year-old man with intellectual disability and osteoporosis in a group home, fell on 19 January 2018 and sustained a spiral femur fracture with internal bleeding. Care workers failed to seek medical a…
56y · Male·acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) i…
Ashley Adrian Lane, a 56-year-old Aboriginal man from the Ngaanyatjarra Lands, died in custody at Kalgoorlie Regional Hospital from acute exacerbation of chronic obstructive pulmonary disease (asthma). He was a remand pr…
heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…
Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…
42y · Female·hanging
Holly Thredgold, aged 42, died by hanging on 28 August 2016, less than 40 hours after inappropriate discharge from Royal Adelaide Hospital ED. She presented on 26 August 2016 severely intoxicated with suicidal ideation a…
14y · Male·Hanging
A 14-year-old boy died by hanging after extensive exposure to domestic and family violence and child abuse, primarily from his father. Child Safety Services involvement began in infancy but failed to apply a trauma-infor…
58y · Male·Pneumonia and urosepsis
Brent Newman, a 58-year-old man with Down syndrome and early-onset dementia, died from pneumonia and urosepsis following inadequate care at an aged care facility. His indwelling catheter was poorly managed, causing ureth…
28y · Female·hypovolaemia due to spleen laceration due to blunt force trauma to the torso
Roberta Curry, 28, was killed by her former partner Lorenzo Deegan after repeated assaults, with a fatal blow causing splenic laceration. Critical failures included: police misclassifying her 000 calls as general disturb…
73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …
Paul Turner, 73-year-old with atrial fibrillation and aortic valve replacement, underwent elective bilateral inguinal hernia repair in August 2018. His cardiologist advised ceasing rivaroxaban 3-4 days preoperatively; ho…
40y · Male·Unascertained; opioid withdrawal-related seizure or cardiac arrhythmia could not…
Micky Craig Revera, a 40-year-old man with chronic heroin addiction, died in Melbourne Assessment Prison on 18 February 2019 from unascertained causes. He was arrested on 12 February after erratic driving, underwent poli…
18y · Male·Multi organ failure due to sepsis from a Group A streptococcus infection
Alex Braes, an 18-year-old from Broken Hill NSW, died of multi-organ failure due to Group A streptococcus sepsis. He presented to Broken Hill Base Hospital three times over 24 hours with knee pain that progressed to seps…
50y · Male·Gunshot wounds to the chest
Mark Sheppard, aged 50, died from gunshot wounds sustained during a police response to a hoax emergency call at a caravan park. He had terminal end-stage COPD with alpha-1 antitrypsin deficiency and was using home oxygen…
37y · Male·Stab wound to the left kidney
A 37-year-old man was fatally stabbed by his de facto partner during a family violence incident. He had a documented history of perpetrating family violence including threats, stalking, choking, and repeated breaches of …
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