2,762 results
76y · Male·Sepsis, with osteomyelitis and infective endocarditis
Alex Mills, a 76-year-old sentenced prisoner with complex medical history including atrial fibrillation, valvular heart disease, and rheumatoid arthritis, died from sepsis caused by osteomyelitis and infective endocardit…
44y · Male·Strangulation
Ashley Phillips, aged 44, was strangled to death by Jason Considine during a consensual sexual encounter on 26 May 2017. This finding reveals systemic failures in community corrections case management. Considine was subj…
45y · Male·Hanging
A 45-year-old man with depression died by hanging after experiencing significant workplace stress. He had consulted his GP in October 2014 regarding grief over his mother's terminal illness and was prescribed sleeping ta…
36y · Male·multiple injuries consistent with a fall from a height
A 36-year-old man with severe depression, social isolation, and recent life crises (job loss, marital breakdown, reduced child contact) posted suicidal messages on social media and stood on a cliff ledge. Police negotiat…
65y · Male·Self-inflicted incised and stab wounds to neck and incised wounds to wrists
James Robert Sowden, aged 65, died by self-inflicted neck and wrist wounds on 28-29 March 2018. He had a history of depression with paranoid features (diagnosed 2003) and autoimmune thyroiditis. In the week before death,…
24y · Male·Environmental exposure in a man with methylamphetamine effect
Dean Jesse Gerrard-Latham, a 24-year-old Indigenous man, died from environmental exposure while acutely intoxicated by methylamphetamine in bushland near Derby, WA. After evading police in a stolen vehicle, he and his co…
56y · Male·Internal blood loss, complications arising from laparoscopic cholecystectomy
Barry Brown, a 56-year-old man, died from internal bleeding after laparoscopic cholecystectomy due to critical systemic failures in post-operative care and diagnosis. Following hypotension at 7:30pm, nursing staff failed…
22y · Male·Hanging
A 22-year-old man with severe chronic treatment-resistant schizophrenia and substance use disorder died by hanging in prison custody. He had been recently discharged from a mental health hospital to police custody follow…
34y · Female·Pneumonia in a woman with intellectual disability and asthma
Simone Grigg, a 34-year-old woman with intellectual disability and asthma, died from pneumonia. She was living in DHHS supported accommodation and attending Amicus day services. On 21 November 2017, she developed respira…
33y · Female·Multiple Injuries
Simone Quinlan, a 33-year-old woman with a history of substance misuse and homelessness, was murdered on 25 August 2015 by her partner Brendan Neil and his associate Wayne Marmo in circumstances of intimate partner viole…
81y · Female·Aspiration pneumonia in an elderly lady
An 81-year-old woman with intellectual disability, phenylketonuria, and severe dysphagia died from aspiration pneumonia following repeated admissions for the same condition. She had been assessed as 'very high risk of as…
8y · Male·acute exacerbation of chronic asthma
An 8-year-old boy with undertreated chronic asthma presented to North West Regional Hospital with acute exacerbation. Initial assessment underestimated severity. Despite initial improvement with salbutamol, ipratropium a…
38y · Male·carbon monoxide toxicity
Samuel Mark Walsh died by carbon monoxide toxicity (suicide) in October 2014 while subject to a custody order for a forensic mental health condition. He had paranoid schizophrenia and had been remarkably stable on clozap…
15y · Male·Gastric perforation with early peritonitis; Acute gastric distension and chronic…
HM, a 15-year-old boy with suspected autism spectrum disorder and depression, died from spontaneous gastric perforation with early peritonitis secondary to acute gastric distension. He had dysfunctional eating patterns, …
74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest; Hassan Khalif Shire Ali: gunshot wo…
A 74-year-old Italian-Australian, Sisto Malaspina, was fatally stabbed during a terrorist attack in Melbourne's CBD on 9 November 2018. Hassan Khalif Shire Ali, aged 30, detonated an improvised explosive device in his ve…
74; 30y · Male; male·Sestilio Malaspina: stab wound to the chest. Hassan Khalif Shire Ali: gunshot wo…
On 9 November 2018, Hassan Khalif Shire Ali committed a premeditated ISIS-inspired terrorist attack in Bourke Street, Melbourne, using an improvised explosive device in his vehicle followed by a knife assault. He fatally…
12y · Female·Undetermined (asphyxiation or choking)
Tiahleigh Palmer, age 12, was murdered on 29 October 2015 by her foster carer Richard Thorburn, who asphyxiated or choked her. The coroner identified critical systemic failures including: inadequate permanency planning b…
47y · Male·acute alcohol intoxication
Julian Horne, 47, died from acute alcohol intoxication at home after 11 hospital admissions in 6 weeks during a severe binge relapse. He had lifelong struggles with alcohol, depression and anxiety, previously tried multi…
43y · Male·Drowning as a consequence of capsized boat
Martin Sydney Cunningham, 43, died by drowning after the fishing vessel Cygnet Lass collided with the tugboat Svitzer Nana near Bowen, Queensland on 25 May 2016. Both vessels were operating on autopilot in a crossing sit…
35y · Male·drowning
A 35-year-old man drowned after falling from a jet ski while operating it without proper qualifications, training, or safety equipment. He could not swim but falsely claimed he could. After being thrown into water during…
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