94 results
46y · Male·Methylamphetamine toxicity and coronary atherosclerosis
A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…
71y · Female·multiple pulmonary thromboemboli and deep vein thrombosis
71-year-old woman presented to ED with signs of circulatory failure (hypotension, tachycardia, tachypnoea, hypoxia) and progressive leg pain/swelling over one week. ECG showed S1Q3T3 pattern consistent with pulmonary emb…
50y · Male·ischaemic heart disease
Paul Reid, a 50-year-old Aboriginal man with severe ischaemic heart disease and poor medication compliance, died of a cardiac arrhythmia during his arrest by South Australian Police. He was highly intoxicated (BAC 0.25%)…
32y · Male·Mixed drug toxicity
A 32-year-old man with bipolar disorder and substance abuse history died from mixed drug toxicity (oxycodone 0.7 mg/L, tramadol, benzodiazepines, cannabis and amphetamines). Emergency services attended after his partner …
72y · Male·Choking on a food bolus
A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff lack of training in safe…
Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …
Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…
36y · Male·Multiple Sharp Force Injuries to Chest and Neck
Mr J, a 36-year-old with a history of first-episode psychosis (2012) and relapse (2014) both associated with methamphetamine use, ceased antipsychotic medication in September 2019 with GP support after achieving 3 years …
25y · Male·Hypoxic ischaemic brain injury due to hanging
Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…
17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest
FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…
39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …
A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …
3y · Female·complications of Influenza B viral infection
Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…
3y · Female·Hypoxic-ischaemic encephalopathy due to chorioamnionitis due to Gardnerella Vagi…
Zamia Ely-Smith died at 3 days of age from hypoxic-ischaemic encephalopathy due to chorioamnionitis following home birth at term. Clinical lessons include: (1) decreased fetal movements at 39+ weeks gestation and hospita…
44y · Female·haemoperitoneum due to ruptured splenic subcapsular haematoma in the setting of …
Kylie Cay, a 44-year-old woman, was brutally assaulted by her partner Justin Turner on 18 June 2016, sustaining rib fractures and other injuries. She was discharged from hospital on 20 June after imaging did not reveal a…
19y · Male·Hanging
Dylon James Ahquee, aged 19, died by hanging in Townsville Correctional Centre on 26 December 2015. Despite documented self-harm and suicidal ideation as a juvenile, no Self-Harm Episode History flag was raised at adult …
30y · Male·Malignant ventricular arrhythmia without myocardial infarction, precipitated by …
Jack Kokaua, a 30-year-old with schizophrenia and coronary artery disease, died from malignant ventricular arrhythmia during a police encounter after absconding from hospital. Contributing factors included positional asp…
80y · Female·acute subdural haematoma following a fall while on warfarin for atrial fibrillat…
Mrs Bowerman, aged 80, fell at home on warfarin anticoagulation and sustained a minor head injury with no initial neurological signs. Paramedic Turnbull assessed her as requiring no transport (TNR), despite her anticoagu…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
76y · Female·Ludwig's angina
A 76-year-old woman with Ludwig's angina presented to urgent care with facial swelling and fever. She was appropriately diagnosed and arrangements made for transfer to a tertiary centre. However, staff failed to recognis…
28y · Male·Hypoxic brain injury as a result of a respiratory arrest, after inadequate respi…
Grant Cook, aged 28, collapsed during a rugby league game after a tackle caused him to fall and hit his head. He suffered a grand mal seizure with snoring/obstructed breathing, leading to respiratory arrest, cardiac arre…
27y · Male·unascertained; likely death from entering water
Thomas Hunt, a 27-year-old man, died after entering the water near Bondi Beach on 23 March 2017, likely after experiencing an acute mental health crisis characterised by paranoid delusions and auditory hallucinations. Mu…
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