2,762 results
3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…
Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
48y · Male·Gunshot wounds to the upper torso
Troy Van Den Bemt, 48, died from gunshot wounds sustained during an attempted armed robbery at a bottle shop in Park Orchards on 28 January 2018. An undercover State Surveillance Unit (SSU) operative fired six shots at V…
59y · Female·mechanical asphyxia
Cheryl Anne Taylor, aged 59, died from mechanical asphyxia when a timber balcony collapsed at a Christmas party on 16 December 2017. The balcony had multiple structural deficiencies: the main support bearer was undersize…
63y · Male·metastatic rectal carcinoma
Jeremy Scott, a 63-year-old prisoner, died from metastatic rectal carcinoma on 3 July 2017. From 2015 onwards, he reported rectal and anal symptoms including pain, bleeding, and palpable masses, which were repeatedly att…
49y · Female and male·Gunshot wound to head inflicted by spouse
Karina Lock was fatally shot by her husband Stephen Lock in a murder-suicide at a McDonald's restaurant on 10 September 2015. The coroner identified multiple systemic failures that failed to protect Ms Lock despite her h…
24y · Female·Shotgun injury to the head
Amy Wensley died from a shotgun wound to the head on 26 June 2014. Whether self-inflicted or inflicted by another remains undetermined. Detectives prematurely concluded suicide on the night of death without thorough inve…
38y · Male·Mixed drug toxicity
DA was a 38-year-old man who died from mixed drug toxicity involving sedating medications and alcohol. He had longstanding severe anxiety and became dependent on codeine and benzodiazepines, initially obtained from multi…
38y · Male·combined effects of acute-on-chronic respiratory disease and cardiomegaly
Marshall Ruben Edgill, a 38-year-old Indigenous man, died in custody from acute-on-chronic respiratory disease and cardiomegaly. He had longstanding obstructive sleep apnoea (OSA), obesity, asthma, and hypertension. Crit…
27y · Male·Effects of fire
Brendon Crippen, 27, died from severe burns sustained in a deliberately set fire at his family's property. He had recently absconded from a Tasmanian psychiatric unit where he was subject to a compulsory treatment order …
0y · Unknown·sepsis leading to multiple organ failure syndrome
A 48-day-old neonate with congenital heart defect presented to the ED with fever and vomiting on 20 September 2019. Initial triage as Category 3 was inappropriate; the child required urgent assessment. The ED intern saw …
Male·sternum, rib and thoracic spine fractures, haemothorax and mediastinal haemorrha…
Stewart James Quirk died from thoracic trauma sustained in a motor vehicle collision on 13 October 2020. He was driving a van while speaking on his mobile phone and collided with a taxi at appropriate speed on clear weat…
15y · Unknown·acute respiratory distress syndrome resulting from multi-organ failure as a cons…
Child A, aged 15, died from acute respiratory distress syndrome resulting from multi-organ failure due to disseminated tuberculosis. He presented to hospital with very advanced post-primary pulmonary tuberculosis requiri…
47y · Male·Hanging
A 47-year-old man with chronic schizophrenia and alcohol dependence died by hanging at a rooming house. He had been non-compliant with antipsychotic medications for months, experiencing severe auditory hallucinations tha…
51y · Female·embolic infarcts complicating infective endocarditis
Melanie Sarah Cooper, aged 51, died from embolic infarcts complicating infective endocarditis secondary to chronic intravenous opioid use. She presented with severe physical deterioration over three days including swolle…
26y · Female·Neck injury due to stabbing
A 26-year-old woman was stabbed twice in the neck and fatally injured by her former de facto partner. Critical clinical and systemic failures preceded her death: her psychologist failed to notify police or health authori…
28y · Female·Complications of a seizure in the setting of prescription drug abuse (pregabalin…
Samantha Leech, 28, died from complications of a seizure in the setting of prescription drug abuse, particularly pregabalin. She obtained approximately 4000 pregabalin tablets over three months by visiting multiple GPs, …
62y · Male·Diabetic ketoacidosis in a man with coronary atherosclerosis and cardiomegaly
Phillip Sealey, 62, presented to his local GP on 27 June 2019 with three weeks of thirst, urinary frequency, nocturia, blurred vision, dizziness and vomiting. The GP diagnosed hypertension and suspected diabetes mellitus…
37y · Male·Acute external and internal blood loss from single stab wound to upper left ches…
MWJ, aged 37, was fatally stabbed by his intimate partner EW on 24 December 2016 during an escalating domestic argument. The coroner identified significant systemic failures in Community Corrections management of both of…
32y · Male·unknown cause, likely natural causes possibly complicated by accident in remote …
Desmond Carr, aged 32, disappeared on 2 August 1979 from a remote worksite near Thangoo Station, Broome, WA, while operating a steam roller for the Main Roads Department. He was in poor health with a history of seizures,…
50y · Male·blunt trauma of the abdomen, pelvis and legs
Retbe Chide Negga, an Ethiopian-born seasonal farm worker, died from crush injuries after his leg became trapped beneath a trailer wheel while attempting to board a moving tractor-trailer at a cherry orchard. Key clinica…
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