797 results
49y · Male·cor pulmonale and chronic bronchitis and emphysema
Graham Murrurkuwuy, a 49-year-old Aboriginal man, died of cor pulmonale and chronic bronchitis/emphysema while imprisoned at Darwin Correctional Centre. He had a long history of smoking and substance abuse. Medical staff…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
17y · Female·mixed drug toxicity
Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…
34y · Male·neck compression due to hanging
A 34-year-old man with longstanding psychiatric illness died by hanging four days after discharge from psychiatric hospital. He had been admitted twice in August-September 1999 with active suicidal ideation and homicidal…
24y · Male·Aspiration of vomit associated with combined drug effect
Martin Raymond Coffey, 24, died from aspiration of vomit associated with combined drug effect while on home detention after serving a prison sentence for traffic offences. He had a history of depression (following the de…
35y · Male·neck compression from hanging
A 35-year-old man with a history of depression, substance abuse, and acquired brain injury from assault was admitted to a psychiatric ward after self-harm with suicidal ideation. He was detained under the Mental Health A…
25y · Male·coronary thrombosis resulting from coronary atherosclerosis
A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
84y · Male·severe head injuries (fracture of skull on right side, subarachnoid haemorrhage,…
An 84-year-old man with severe respiratory disease, cardiac failure, poor vision and confusion fell from a first-floor hospital window, sustaining fatal head injuries. The coroner found the death was not deliberately sel…
78y · Male·suppurative bronchitis complicating chronic obstructive airways disease (emphyse…
A 78-year-old man died of suppurative bronchitis complicating end-stage emphysema at a supported residential facility. Key clinical concerns include: (1) the general practitioner's reliance on unvetted aged care staff to…
31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…
Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …
0y · Male·multi-organ failure from septicaemia following surgical reduction of intussuscep…
Nathan Wrench, 11 weeks old, presented to Queanbeyan Hospital on 14 October 1996 with persistent vomiting for 3 days. GP Dr R. diagnosed viral infection with possible reflux, admitted for observation, and managed conserv…
21y · Male·Suffocation from hanging
Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial f…
74y · Male·cardiac arrhythmia in an elderly man with chronic obstructive pulmonary disease …
Ian Head, a 74-year-old man with chronic obstructive pulmonary disease, hypertension, and chronic kidney disease, died from cardiac arrhythmia following COVID-19 infection while imprisoned at Acacia Prison. He had receiv…
85y · Female·Sepsis relating to an infected right shoulder wound (including MRSA)
Ellen Plymin, aged 85, sustained a fractured humerus in a fall and underwent surgical fixation at Western Hospital on 10 May 2007. She returned to Westgate Aged Care Facility post-operatively on 14 May. By 28 May, wound …
66y · Male·Complications of chronic lithium therapy
Sydney Kennedy, a 66-year-old man with intellectual disability and bipolar affective disorder, died from complications of chronic lithium therapy. He had been on lithium for years with annual psychiatric review, but ther…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
Amanda Dana Tauai, 21 years old, died from septic shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote …
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