2,762 results
58y · Male·blunt force head injury
Frederick Peisley, an Aboriginal man with acquired brain injury and schizoaffective disorder, died from a head injury after falling from stairs at an aged care facility. Critical failures included poor communication of h…
19y · Male·Traumatic asphyxia
Blaine Rozs, 19, died from traumatic asphyxia after falling from a turf harvester while reversing. He was struck and crushed underneath the machine. Clinical lessons include: (1) traumatic asphyxia causes death within mi…
3y · Male·Streptococcus pyogenes group A pneumonia
Hugo Gardiner, a 3-year-old boy with fever, cough, vomiting and diarrhoea, was assessed twice at Mount Beauty Medical Centre on 23 December 2015 by GPs who diagnosed viral upper respiratory tract infection. Both doctors …
48y · Female·Sepsis due to pulmonary and cutaneous infections, with urinary tract infection a…
A 48-year-old tetraplegic woman died from sepsis originating from a necrotic sacral pressure wound. Multiple system failures contributed: inadequate pressure sore prevention at the disability care provider (air mattress …
10y · Male·Unascertained - sudden and unexpected death; evidence did not allow determinatio…
Ezekiel Howard, a 10-year-old boy, died suddenly in his sleep on 12 September 2011. His death remains unexplained despite extensive investigation. The coroner could not determine whether death resulted from undiagnosed e…
40y · Male·UNDETERMINED - natural causes (most probably natural disease; starvation could n…
Miroslaw Dziczkowski, a 40-year-old man with paranoid schizophrenia managed under a Community Treatment Order, disappeared in January 2013 after withdrawing $7300 and relocating to a caravan park without notifying his me…
Organising pneumonia (Sandra Boney and Norman Boney); Organising pneumonia compl…
Three Aboriginal Australians from Walli Reserve (Sandra Boney, 40; Norman Boney, 46; Roger Adams, 37) died within two months in early 2015 following consumption of illegally home-distilled methanol-containing alcohol ('m…
22y · Male·aspiration pneumonia complicating resuscitation for cardiac arrest due to neck c…
A 22-year-old male with acute psychosis was admitted to a mental health ward under a Level 1 treatment order. Despite half-hourly observations, he hung himself using an electrical cord in his wardrobe. The ward layout ha…
56y · Female·asthma
Maria Valler, a 56-year-old woman with intellectual disability and autism who was living in Department of Health and Human Services (DHHS) supported accommodation, died from acute asthma while returning from a walking ex…
2y · Male·Hypoxic-ischaemic encephalopathy due to cardiorespiratory arrest secondary to up…
A 2-year-old boy presented to hospital with croup (parainfluenza 1 laryngotracheobronchitis) on 13 July 2013. He was given nebulised adrenaline by ambulance and dexamethasone at hospital, then discharged after only 3 hou…
29y · Male·mixed drug toxicity including heroin
Troy Daniel Saint, a 29-year-old man with amphetamine and opioid dependence, died of mixed drug toxicity including heroin while admitted to The Melbourne Clinic for voluntary detoxification. Critical failures occurred: (…
77y · Male·Stroke; cardiogenic shock; severe aortic stenosis with three vessel coronary art…
Mr Neitsch, a 77-year-old with severe aortic stenosis, peripheral vascular disease, and reduced left ventricular function, underwent elective coronary angiography at Princess Alexandra Hospital on 21 May 2015. The proced…
25y · Male·traumatic basal subarachnoid haemorrhage due to vertebral artery dissection
Phillip Hughes, a 25-year-old professional cricketer, died from traumatic basal subarachnoid haemorrhage caused by vertebral artery dissection after being struck on the neck by a cricket ball during a Sheffield Shield ma…
84y · Female·Unable to determine exact cause; likely misadventure, accident, or sudden health…
Gaida Coote, 84, disappeared from Ku-ring-gai Wild Flower Garden on 3 December 2014 while volunteering. Her body was never found. Critical delays occurred: when her daughter reported her missing on 4 December at 8:20pm, …
55y · Female·Cardiac tamponade due to haemopericardium due to acute ruptured myocardial infar…
A 55-year-old woman with extensive coronary artery disease presented for elective stent placement to her left anterior descending artery. During the procedure, a small diagonal branch vessel was occluded—a recognised com…
36y · Female·myocardial infarction as a consequence of severe focal coronary artery atheroscl…
Krista Lloyd, 36-year-old woman with undiagnosed coronary artery disease presenting with prior chest pain radiating to neck/jaw, suffered sudden out-of-hospital cardiac arrest on 1 May 2015 at home. Initial ECG showed po…
62y · Female·end-stage heart failure due to cardiac amyloidosis
A 62-year-old woman with end-stage cardiac amyloidosis died from cardiogenic shock approximately 90 minutes after being placed on a Level 1 inpatient treatment order. She had wished to discontinue treatment, reflecting h…
33y · Female·Blunt impact injuries
Anita Kalnins, a 33-year-old childcare worker, died when a large tree branch fell on her while she was camping on crown land at the Murray River foreshore near Brimin. The branch fell unexpectedly from a Red Gum tree, an…
49y · Male·Ligature compression of the neck (hanging)
A 49-year-old sentenced prisoner died by suicide via ligature compression of the neck at Acacia Prison in Western Australia. The deceased had a psychological profile characterised by denial and minimisation of adverse ex…
85y · Male·Probable pneumonia following a hip fracture (comminuted fracture of right acetab…
Richard Weily, 85, with Lewy-body dementia, Parkinson's disease, and cardiac disease, was admitted to Roy Fagan Centre (RFC) mental health facility on 13 June 2013 under Mental Health Act provisions for management of acu…
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