2,762 results
84y · Female·Complications of pelvic fractures sustained in a traumatic incident
An 84-year-old woman with dementia died from complications of pelvic fractures sustained when another dementia-affected resident pushed her during an altercation over food in an aged care facility. She developed bilatera…
39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …
A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …
71y · Female·Complications post aortic endarterectomy
A 71-year-old woman died from complications following elective aortic endarterectomy for leg claudication. Post-operatively, she developed acute bilateral lower limb ischaemia with absent pulses, pale/mottled skin, and s…
61y · Male·metastatic oesophageal neuroendocrine carcinoma
Terrence Wells, a 61-year-old prisoner, died from metastatic oesophageal neuroendocrine carcinoma in December 2018. Cancer was diagnosed in April 2018 after he reported difficulty swallowing, which was initially attribut…
83y · Female·Aspiration bronchopneumonia in a setting of cerebral infarction
Ms Patricia Grant, 83, died from aspiration bronchopneumonia following cerebral infarction while living with her son and daughter-in-law. She experienced severe neglect and elder abuse in her final years: cessation of ep…
73y · Male·Neck compression in the circumstances of hanging
A 73-year-old man with severe depression and suicidal ideation died by hanging at a private psychiatric facility on 9 February 2019 during voluntary admission. He was assessed as low risk despite recent suicidal statemen…
67y · Male·Fulminant liver failure
A 67-year-old man presented to his GP with discoloured urine. Blood tests revealed acute liver toxicity but critical results were communicated via facsimile, with unclear timing of GP's review. The patient deteriorated r…
0y · Male·Pneumonia in the setting of malnutrition
Baby A, born at home without medical assistance, died at 19 days old from pneumonia complicated by severe malnutrition and dehydration. He weighed 2.87kg at autopsy, far below his reported 4kg birth weight. He had diffic…
43y · Female·Neck compression
TCW, age 43, died from neck compression inflicted by her adult son OMP (age 17 at time of incident, now convicted of manslaughter). OMP had intellectual disability (IQ 59), autism spectrum disorder, and hypersexual disor…
73y · Female·Unknown due to decomposition
Mrs Chrupalo, a 73-year-old woman with physical disability, cognitive impairment and alcohol dependency, was discharged from Dubbo Base Hospital on 8 July 2015 against medical advice despite being bedbound and dependent …
65y · Female·choking on a tangerine
Ms Shelley Young, a 65-year-old woman with long-standing schizoaffective disorder and multiple complications from chronic antipsychotic use including dysphagia and tardive dyskinesia, died from choking on a tangerine whi…
29y · Male·ligature compression of the neck (hanging)
Brett Ashley Duturbure, aged 29, died by suicide via hanging at Wyndham Work Camp on 14 November 2019. The coroner identified critical systemic failures in the Department of Justice's management of his care. The Departme…
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…
4y · Unknown·Drowning
A 4-year-old boy drowned in a resort pool during a family birthday party on 13 December 2020. Despite wearing a buoyancy vest initially, he removed it to use water slides more freely. While approximately 8 adults were pr…
4y · Male·Drowning
A 4-year-old boy drowned in a resort pool during a birthday party. He had been wearing a buoyancy vest initially but removed it to use water slides more freely. While approximately 20 people attended (8 adults), supervis…
Death from fire exposure during bushfire - the finding does not concern individu…
On 18 March 2018, a major bushfire commenced in an electrical easement near Reedy Swamp and rapidly spread to the coastal town of Tathra on the NSW South Coast, destroying approximately 1,400 hectares of bushland and dam…
15y · Male·ligature compression of the neck (hanging)
Aboriginal child in out-of-home care died by hanging following relationship breakdown. He experienced foetal alcohol spectrum disorder, early trauma and neglect, and 34 different living arrangements. Despite specialist m…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring…
20y · Male·Multiple injuries from fall from height
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, died from multiple injuries after impulsively jumping an 8-metre wall at a hospital ambulance bay on 5 November 2019. He was in custo…
55y · Female·acute myocardial infarction due to right coronary artery thrombosis
A 55-year-old woman presenting to the emergency department with 24 hours of chest pain, arm pain, sweating and vomiting was discharged without an ECG or troponin measurement. She had an abdominal CT suggesting cholecysti…
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