2,762 results
74y · Female·Subdural haemorrhage following a fall in a woman with multiple medical comorbidi…
Mrs Chettle, a 74-year-old aged care resident with multiple comorbidities including dementia, schizoaffective disorder, and a nine-fall history in twelve months, fell from a shower chair while a personal care assistant b…
Multiple causes across seven deaths: severe blunt trauma, crush injuries, trauma…
This coronial inquest examined seven quad bike fatalities in Tasmania between 2012-2015. The deceased included farmers, workers, and recreational riders aged 21-75 years. Key findings: inadequate training was a significa…
51y · Male·mixed prescription drug toxicity (amisulpride, diazepam and mirtazapine)
A 51-year-old man with schizophrenia, depression and early dementia died from mixed prescription drug toxicity (amisulpride, diazepam, mirtazapine) after a deliberate overdose. He had recently presented to hospital with …
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
61y · Female·multi organ failure due to abdominal sepsis
Lesley Arndell, aged 61, died from multi-organ failure due to abdominal sepsis after undergoing a Whipple's procedure for pancreatic cancer. Key clinical lessons include: (1) patients with previous bariatric surgery requ…
76y · Male·Drowning
Yousif Yousif, a 76-year-old man with dementia, wandered away from an unsuitable Christmas party venue at a community health centre and drowned in a nearby creek. Key failures included: inadequate risk assessment for ven…
27y · Male·ligature strangulation
A 27-year-old male with treatment-resistant schizophrenia died from ligature strangulation by a co-patient at a secure forensic mental health facility. The deceased had multiple admissions for medication non-compliance a…
Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…
Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…
30y · Male·Death by drowning at sea, likely following suicide. Exact manner not determined.
Joseph Leon Patterson, a 30-year-old man, disappeared on 26 July 1974 from Albany, Western Australia, after telling his close friend John Oreo he intended to sail his yacht (the Enid) out to sea and harm himself. He was …
76y · Female·dehydration, hypothermia and exhaustion
Elizabeth O'Pray, a 76-year-old woman with a history of transient ischaemic attack and early cognitive difficulties, became lost while walking in bushland near Katoomba, NSW on 7 March 2016. Despite extensive police sear…
85y · Female·sepsis, with aspiration pneumonitis being an antecedent cause. Iatrogenic injury…
Lorraine Barnes, an 85-year-old woman admitted to Wollongong Private Hospital for convalescence, died from sepsis with aspiration pneumonitis following iatrogenic lung injury. She developed severe malnutrition and electr…
0y · Male·Unascertained
A 10-week-old boy born at 35 weeks gestation was found asleep on his mother's chest while she was asleep on a couch and died from an unascertained cause. Post-mortem toxicology detected methamphetamine and cannabis; the …
77y · Male·Hypothermia
Raymond Speechley, aged 77 with dementia, absconded from an aged care secure unit on 7 July 2016 and died from hypothermia in bushland. Critical systemic failures at the facility included: failure to identify him as an a…
23y · Male·Multiple injuries sustained following collision with a train
A 23-year-old man with a history of schizophreniform disorder, depression, and previous suicide attempts absconded from a mental health triage facility after being involuntarily admitted. He had previously absconded in 2…
Kayla Ewin: Unascertained (SUDI 0+); Iziah O'Sullivan: Unascertained (SUDI 0)
Two infants died suddenly and unexpectedly at home with unascertained causes classified as SUDI (Sudden Unexpected Death in Infancy). Key clinical lessons include: improved documentation of scene temperature (relevant fo…
49y · Male·Hanging
A 49-year-old man with major depression, suicidality and previous suicide attempts was admitted to the Acute Mental Health Unit at Nepean Hospital under involuntary detention. He died by hanging on 27 May 2017 during an …
49y · Female·Anorexia
Sonya Szala, 49, died from anorexia nervosa after suffering severe metabolic derangement and extreme emaciation. She became a recluse following her mother's death in 2016 and progressively deteriorated both physically an…
Male·Unascertained (fatal injuries from vehicle crash and/or thermal effects of bushf…
Four people died in a catastrophic bushfire near Scaddan, Western Australia in November 2015 while attempting to evacuate. Kym Curnow, a local farmer and volunteer firefighter, was driving his own vehicle, while Tom Butc…
4y · Male·respiratory failure secondary to pneumonia on a background of Niemann Pick Type …
Lebron Martin was a 4-year-old Aboriginal child with Niemann-Pick Type C disease, a progressive neurodegenerative disorder. He died from respiratory failure secondary to pneumonia in December 2017. Four months prior to h…
36y · Male·Septicaemia and cerebral artery air embolism, due to complications related to cl…
Jamie Lawrence Mitchell, 36, died from septicaemia and cerebral artery air embolism complicating radiofrequency ablation for atrial fibrillation. He developed an atrioesophageal fistula after cardiac ablation at Royal Ad…
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