2,765 results
18y · Male·acute neck compression due to hanging
Shane Blunden, aged 18, died by hanging in Yatala Labour Prison on 19 September 2011. He was a remanded prisoner with an extensive history of self-harm, including cutting, swallowing batteries and razors, and a previous …
Female·Multiple injuries due to motor vehicle trauma
Rebecca Louise Fenton died in a motor vehicle collision on the Capricorn Highway near Blackwater, Queensland when her vehicle rear-ended a stationary utility waiting to turn right at an inadequately designed intersection…
63y · Male·Multisystem organ failure, pneumonitis and sepsis; complications arising from a …
A 63-year-old man died on 11 March 2008 from multisystem organ failure, sepsis and pneumonitis following a fall. He was admitted to Dandenong Hospital with rib fractures and pelvic injuries. Clinical deterioration occurr…
48y · Male·Crush injury to the chest from collapse of a gazebo structure
A 48-year-old qualified builder, Stephen James Peace, was fatally crushed when a gazebo he was constructing collapsed on 2 May 2006. The structure was designed to be supported on steel posts embedded 900mm deep in concre…
37y · Male·Unascertained (death in custody)
Craig McMillan, 37-year-old male with chronic schizophrenia, died of undetermined cause (death in custody) after being transported by police divisional van to hospital. Despite documented tachycardia from Risperidone, th…
49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…
Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…
59y · Female·head injury
Ms Athiel Deng, a 59-year-old Sudanese refugee, was fatally assaulted by her son Majang Ngor during an acute psychotic episode induced by cannabis and methamphetamine use. Ngor had a documented first psychotic episode in…
28y · Male·Undetermined but suspicious
Sun Peng, a 28-year-old Chinese national crew member on the vessel Great Talent, disappeared from the ship anchored at Weipa on 23 March 2014. He had sustained a hand laceration after smashing a bowl during an altercatio…
4y · Female·closed head injury with contributing extensive subcutaneous and intramuscular ha…
Chloe Lee Valentine, aged 4 years 5 months, died on 20 January 2012 from closed head injury with extensive subcutaneous and intramuscular haemorrhage. The fatal injuries resulted from repeated trauma inflicted during a p…
51y · Female·Mixed drug toxicity (amitriptyline, chlorpheniramine, diazepam, codeine) complic…
A 51-year-old woman died from mixed drug toxicity (amitriptyline, chlorpheniramine, diazepam, codeine) complicated by biventricular heart hypertrophy. She had chronic back pain treated with opioids and used excessive ove…
39y · Female·Hypoxic brain injury secondary to multiple hypovolaemic cardiac arrests from cat…
Linda Parker, aged 39, died from hypoxic brain injury following catastrophic postpartum haemorrhage from placenta increta during caesarean delivery. Critical lessons: (1) Placenta increta risk was not detected prenatally…
53y · Male·metastatic pancreatic cancer
Joseph Mallia, a 53-year-old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possib…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
2y · Male·Hypoxic brain damage due to drowning in a swimming pool
A 2.5-year-old boy drowned in a non-compliant private swimming pool after accessing it through a collapsed boundary fence that had been down for months. The coroner found the death preventable and examined systemic failu…
53y · Male·Complications arising from blunt force trauma to the head
Colin David Johnson, aged 53, died from complications of severe blunt force head trauma sustained during an assault in a prison day room on 23 April 2011. The attack occurred in full view of a prison office with a clear …
72y · Female·Hanging
Chang Ying Xu, a 72-year-old Chinese-speaking woman with severe spinal cord compression, chronic pain, and depression, died by hanging during respite care at an aged care facility. While her depression history and multip…
0y · Female·meconium aspiration
A full-term female infant (41 weeks 3 days) died from meconium aspiration during a planned home water birth attended by an experienced midwife. The mother had gestational diabetes and a history of macrosomic babies—risk …
45y · Male·Complications of heat stroke in a man with schizophrenia
Christopher Dokos, a 45-year-old man with schizophrenia on Clozapine treatment, died during the extraordinary January 2014 Victorian heatwave. He had multiple heat-vulnerability risk factors: mental illness, antipsychoti…
50y · Female·Complications of heat stroke in a woman with schizophrenia
A 50-year-old woman with long-standing schizophrenia treated with clozapine died from complications of heat stroke during an unprecedented Victorian heatwave. She and her partner were not contacted by mental health servi…
29y · Female·Multiple injuries due to fall from height
A 29-year-old woman with rapidly deteriorating mental health presented to Ipswich Hospital ED triaged as ATS Category 3 requiring assessment within 30 minutes. Multiple systemic and clinical failures delayed appropriate …
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