2,762 results
2y · Male·traumatic head injury
A 2-year-7-month-old boy died from traumatic head injury inflicted by person(s) unknown after experiencing severe and escalating physical abuse over weeks. Despite 13 reports to FACS (now DCJ) between 2010-2012, includin…
49y · Male·Stab wound to the chest
A 49-year-old man with anxiety and depression died from a self-inflicted stab wound to the chest sustained during police response to a domestic violence call. He had brought tools and weapons to his ex-partner's home. Wh…
Bearham: hypoxic brain injury from hanging; Fisher: asphyxiation from hanging by…
Four inpatient suicides occurred at The Canberra Hospital mental health units between January 2015 and November 2016: three by hanging and one by jumping. The coroner found systemic failures including inadequate ligature…
22y · Male·Drowning
A 22-year-old university student with recent substance use presented to ED following violent behaviour. He had facial trauma with mild head injury and abnormal metabolic parameters. Initial management appropriately prior…
40y · Male·Mixed drug toxicity
Shae Paszkiewicz, a 40-year-old man with a long history of drug dependence and incarceration, died from mixed drug toxicity five days after being found unconscious following opioid injection. He had been released from pr…
30y · Male·Head injury due to industrial accident
Daniel Springer, a qualified boilermaker, sustained fatal head injuries while removing large external wear plates from an excavator bucket at an open-cut coal mine using an air carbon arc gouger. The wear plates had accu…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…
48y · Male·hanging
Dimitrios Mavris, a 48-year-old man arrested for drug importation, died by hanging in the Surry Hills Cells Complex on 25 May 2018, approximately 40 hours after being taken into custody. He was initially assessed as pres…
0y · Female·head and neck injuries
A 4-month-old girl (Baby H) died from head and neck injuries caused by violent shaking inflicted by her mother on 28 May 2017. She had presented to an emergency department on 10 May 2017 with facial bruising, which physi…
24y · Female·Cardiac conducting system disease leading to asystole against a background of a …
A 24-year-old woman with complex congenital cardiac disease, cerebral palsy, and hydrocephalus was admitted to a secondary hospital with a respiratory tract infection and bradycardia with left bundle branch block. She de…
37y · Male·hypoxic encephalopathy due to asphyxia from hanging
Joseph Aaron Lattimer, aged 37, presented to the Royal Hobart Hospital Emergency Department at 5:02am on 10 July 2016 in mental health crisis with suicidal ideation, correctly triaged as Category 3 (urgent, requiring ass…
52y · Female·Neutropenic sepsis leading to multi-organ failure due to capecitabine toxicity
Mrs L, a 52-year-old woman with T2N0M0 rectal cancer, died from neutropenic sepsis and multi-organ failure secondary to severe capecitabine toxicity on 31 October 2018. She commenced neoadjuvant chemotherapy with capecit…
24y · Female·Head injury from repeated blunt force trauma
A 24-year-old woman was fatally assaulted by her intimate partner after a period of escalating domestic and family violence. The perpetrator had a documented history of violent DFV across multiple relationships, with pri…
4y · Male·Intra-abdominal injuries from blunt force trauma (ruptured duodenum and lacerate…
Tyrell Cobb, a 4-year-old boy, died from intra-abdominal injuries caused by blunt force trauma inflicted on two separate occasions between 22-24 May 2009. Postmortem revealed a ruptured duodenum and lacerated mesentery c…
34y · Female·Head injuries from blunt force trauma (multiple blows from axe); abdominal injur…
A 34-year-old pregnant woman died from severe head and abdominal injuries inflicted by her estranged partner in a domestic violence homicide. The death followed escalating domestic and family violence (DFV) including phy…
Female·suicide by firearm
A woman in rural Victoria died by suicide using a firearm. She had presented to her GP with depressive symptoms and was referred to mental health services, but there were delays in accessing psychiatric care. The coroner…
70y · Male·carcinoma of the lung
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…
31y · Male·positional asphyxia due to synthetic cannabis use and obesity
Christopher Mark Malyschko, a 31-year-old male imprisoned for life, died in a Northern Territory prison cell from positional asphyxia caused by synthetic cannabis (Kronic) use combined with obesity. Clinical and systemic…
75y · Male·cerebral metastatic malignancy (lung cancer with brain metastases)
Kenneth Ballard, aged 75, died in prison custody from cerebral metastatic lung cancer. He had been diagnosed with chronic lymphocytic lymphoma in 2012 and managed at Mount Gambier Prison. In late 2014, Mr Ballard refused…
56y · Male·aspiration pneumonitis secondary to airways obstruction from squamous cell carci…
Edgar Forrester, a 56-year-old Aboriginal man, died of aspiration pneumonitis secondary to oesophageal squamous cell carcinoma with metastases while in custody. He presented with progressive dysphagia from September 2019…
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