2,762 results
25y · Female·acute haemorrhage due to severed femoral artery caused by a stab wound to the th…
Sasha Loreen Napaljarri Green, 25, died from acute haemorrhage due to a severed femoral artery from a stab wound to the thigh, found in scrubland near Tennant Creek in November 2013. The coronal investigation identified …
23y · Male·Hypoxic-ischaemic encephalopathy due to hanging
Zachary James David Holstein, age 23, died by suicide by hanging in Woodford Correctional Centre on 8 February 2016 (declared extinct 12 February 2016). He had a history of substance abuse, self-harm, and mental health d…
26y · Female·Pulmonary embolism as a consequence of dislodged deep vein thrombosis
Naomi Smith, aged 26, died from pulmonary embolism caused by dislodged deep vein thrombosis while in ICU at Royal Darwin Hospital. She had complex mental health needs (BPD, PTSD, depression) and morbid obesity. The criti…
75y · Male·Right haemothorax complicating intercostal catheter insertion for the treatment …
Giuseppe Costa, 75, died from right haemothorax following intercostal catheter insertion for pleural effusion drainage. Critical failures in clinical management included: inadequate documentation of pleural fluid drainag…
59y · Female·complications of intra-abdominal sepsis, including multi-organ failure and bowel…
59-year-old woman died from intra-abdominal sepsis, multi-organ failure and bowel perforation following median hepatectomy for cholangiocarcinoma. Key clinical issues included: surgical delays of 20 days between stent in…
62y · Male·drowning
James Lee Osborn, aged 62, died by drowning in the Derwent River on 30 June 2016 after a rapid deterioration in mental health. He had a long history of depression but experienced acute decompensation with paranoid delusi…
Female·Sudden Unexpected Death in Infancy (SUDI), otherwise undetermined
Two infants died suddenly and unexpectedly. The first child died at home at 3 months of age in an unsafe sleeping environment with multiple soft items in her cot; the second died in temporary care at 19 days of age. Both…
41y · Male·Sudden unexpected death in epilepsy (SUDEP)
Rohan Grindrod, a 41-year-old man with acquired brain injury and epilepsy following a 2007 motor vehicle accident, died of Sudden Unexpected Death in Epilepsy (SUDEP) at his home on 16-17 November 2011. He had a Personal…
27y · Male·Loss of airway control and blockage due to aspiration from complications of a sm…
Dr R., a 27-year-old physician with cystic fibrosis, died from aspiration and airway blockage secondary to a small bowel obstruction whilst under dual respiratory-surgical care at Westmead Hospital. Critical clinical les…
53y · Male·Choking on food bolus in pharynx, with Huntington's disease and coronary atheros…
Paul Joseph Milward, aged 53 with Huntington's disease causing cognitive impairment and swallowing difficulties, died from choking on a bread sandwich while unsupervised in his aged care room. His care plan specified min…
Unknown·Acute myeloid leukaemia (AML)
Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of…
acute myeloid leukaemia
Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originat…
0y · Female·hypoxic brain injury following respiratory arrest due to accidental suffocation …
A 24-day-old infant died from hypoxic brain injury following accidental suffocation whilst co-sleeping with her intoxicated mother. The parents were known to child protection services (CPS) due to intellectual disabiliti…
53y · Female·sepsis and multiple organ failure attributable to infarction/necrosis of small b…
A 53-year-old woman with Type II diabetes, obesity, and Korsakoff dementia presented with acute severe abdominal pain from superior mesenteric artery (SMA) thrombosis at 3:00 AM on 19 August. Despite elevated lactate, me…
21y · Female·drowning
Bethany Farrell, a 21-year-old UK tourist on her first scuba dive, became separated from her instructor in poor visibility (3m) at Blue Pearl Bay. She surfaced in distress for 40+ seconds but was not seen by the designat…
83y · Female·Combined effects of severe malnutrition and infection (septicaemia secondary to …
Mrs Clark, 83, died from severe malnutrition and infection including septicaemia from an infected sacral pressure ulcer that had existed for 7 months. She was admitted to hospital in a deplorable state with severe pressu…
0y · Female·Unascertained
A four-month-old girl died in an unsafe sleeping environment while staying with relatives in Sydney. She was placed in a pram in her parents' bedroom and was found not breathing on the morning of 17 August 2014. The exac…
Unknown·Drowning following blunt trauma to the head (Fletcher); drowning following blunt…
Two experienced boatmen, aged 82 and 81, drowned following the capsizing of their 4.92-metre aluminium fishing vessel in heavy seas off Park Beach, Tasmania. Despite excellent safety practices, current boat licences, and…
28y · Female·aspiration of gastric contents complicating laxative abuse
A 28-year-old woman died from aspiration of gastric contents complicating severe laxative abuse. She fabricated a terminal cancer diagnosis to conceal anorexia nervosa and factitious disorder. During a RAH admission, a C…
5y · Male·complications of blunt force injury to the head
A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …
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