2,762 results
Unknown·acute fentanyl toxicity; acute oxycodone toxicity; multiple drug toxicity; opioi…
Four adults died from opioid overdoses (fentanyl and oxycodone) in Queensland between 2012–2014. All obtained prescriptions from multiple doctors ('doctor shopping') without effective detection. Systemic failures include…
42y · Female·Multiple injuries (motor vehicle impact — motorcycle passenger)
A 42-year-old woman died as a motorcycle pillion passenger following a motor vehicle collision on the Great Alpine Road. Her male partner lost control of his motorcycle when it encountered a 70mm road defect ('shove') on…
93y · Female·blunt trauma with head injury on a background of ischaemic heart disease
Dorothy Mavis Baum, 93, died at Flinders Medical Centre from blunt trauma with head injury following an unprovoked assault by another nursing home resident with a plastic chain. Critical clinical failures occurred: the n…
41y · Male·Cerebral hypoxia and bronchopneumonia; contributing factors: toxic megacolon, ce…
David Orton, a 41-year-old man with cerebral palsy, intellectual disability, and severe kyphoscoliosis, died from cerebral hypoxia and bronchopneumonia complicated by toxic megacolon and Salmonella infection. Over 18 mon…
58y · Male·Complications of chemotherapy for the treatment of Hodgkin lymphoma
Mettaloka Halwala, 58, died from complications of bleomycin toxicity during Hodgkin lymphoma chemotherapy. A PET scan on 11 November 2015 showed widespread lung uptake suggestive of bleomycin pneumonitis, but the haemato…
61y · Male·exposure and dehydration, preceded by alcohol withdrawal and chronic alcoholism
A 61-year-old man with chronic alcoholism was admitted to hospital for alcohol withdrawal management. He became confused and paranoid on the ward, received appropriate medication, but left hospital unobserved approximate…
1y · Female·Sepsis (Group A Streptococcus)
A nearly 16-month-old girl died from Group A Streptococcal sepsis after presenting to a regional private hospital emergency department. She had been seen multiple times by different GPs in the preceding weeks with viral …
33y · Female·hanging, self-inflicted with intention of taking her own life
Naomi Watson Ley, a 33-year-old woman with a history of depression and borderline personality disorder, was admitted to Royal North Shore Hospital following suicidal ideation after medication changes (moclobemide to cita…
Female·not established beyond reasonable doubt
This finding concerns four missing persons from Nannup, Western Australia (Chantelle McDougall, Leela McDougall, Tony Popic, and Simon/Gary Felton) who disappeared on or around 16 July 2007. While the coroner found reaso…
Female·Unknown; coroner could not establish deaths beyond reasonable doubt
This coronial inquest investigated the disappearance of four people from a rural property in Nannup, Western Australia in July 2007: Chantelle McDougall (27), her daughter Leela, Tony Popic (40), and Simon (Gary Felton) …
78y · Male·Heart failure or arrhythmia, secondary to ischaemic heart disease
Peter Woodcroft, 78, suffered a medical emergency (heart failure or arrhythmia secondary to ischaemic heart disease) at 4:32am and called Triple Zero but could not articulate what he needed. Police did not attend his Wat…
17y · Female·Hanging
Tahlia Peden, a 17-year-old Ngunnawal woman, died by hanging ten days after being sexually assaulted. She was assessed by Wagga Sexual Assault Service but a critical breakdown in the referral pathway meant Goulburn SAS n…
25y · Male·drowning
Matthew Leary, 25, died by suicide at Watsons Bay on 28 November 2014 after three psychiatric admissions in one month. Key clinical lessons: mental health clinicians at Prince of Wales Hospital and St Vincent's Hospital …
71y · Male·cardiac arrest due to hyperkalemia due to acute on chronic renal failure, with r…
John Bell, a 71-year-old man with history of bowel cancer, ischaemic heart disease, and chronic renal failure, underwent elective ileostomy reversal surgery. He died from cardiac arrest due to hyperkalemia and metabolic …
67y · Female·Sepsis as a result of gastric perforation
Margaret Pegum, aged 67, died from sepsis following gastric perforation after an intragastric balloon (IGB) procedure for weight loss. She had undergone fundoplication for hiatus hernia in 2012. Despite prior gastric sur…
79y · Male·external neck compression as a result of hanging
A 79-year-old man with bipolar affective disorder and a documented history of medication non-compliance died by suicide while living in rural NSW. He had been subject to a Victorian Community Treatment Order (CTO) requir…
62y · Male·Cerebral ischaemic injury due to hanging
Gerard Helliar, a 62-year-old man with severe bipolar affective disorder, died from hanging in Frankston Hospital psychiatric ward on 16 November 2012 after an involuntary admission for treatment-resistant depression wit…
25y · Male·Electrocution
Matthew Ross, 25-year-old carpenter, died from electrocution at 5:07 PM on 11 July 2013 while installing guttering on construction scaffolding. His body completed an electrical circuit between a metal scaffold pole (hand…
86y · Male·Aspiration Pneumonia secondary to Recurrent Colorectal Carcinoma
An 86-year-old man died from aspiration pneumonia following bowel preparation for elective colonoscopy. He was admitted to an outlying ward rather than the gastroenterology unit, where nursing staff documented multiple e…
25y · Male·Aspiration pneumonia secondary to methadone toxicity
Steven Claude Freeman, a 25-year-old Aboriginal man, died of aspiration pneumonia secondary to methadone toxicity on 27 May 2016, while incarcerated at the Alexander Maconochie Centre in the ACT. He was assessed as opioi…
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