55y · Male·Ascent barotrauma resulting in cerebral arterial gas embolism (CAGE) and drownin…
A 55-year-old man with undiagnosed viral myocarditis and cardiomegaly died from cerebral arterial gas embolism (CAGE) during a scuba dive at 37 metres depth. Despite being advised by his cardiologist not to dive, he igno…
44y · Female·salt water drowning due to ascent barotrauma (cerebral arterial gas embolism)
Jennifer Lee Barrington, age 44, died from salt water drowning due to ascent barotrauma (cerebral arterial gas embolism/CAGE) during a recreational scuba dive. She had significant undisclosed medical conditions including…
34y · Male·extensive blood loss from acute gastric erosions following severe scalding of th…
Neil Summerell, a 34-year-old man with intellectual disability, epilepsy, and vision/hearing impairment, died from acute gastric erosions following severe scalding injuries sustained on 29 November 1999. He was scalded t…
16y · Male·Gunshot wound to the head
A 16-year-old boy with a 5-year history of depression, multiple suicide attempts, and suicidal ideation died by self-inflicted gunshot wound at school on 1 August 2001. He had been under psychiatric care for 10 months, p…
3y · Male·unascertained
Mohammed Tartoussi, aged 3 years 11 months, presented to Bell Street Family Medical Centre on 28 June 2003 with chest pain and mild upper respiratory symptoms. He was diagnosed with mild symptoms and given prednisolone. …
45y · Male·Bullet wound to the head - self-inflicted
A 45-year-old man with recurrent major depression died by self-inflicted gunshot wound in April 2000. His psychiatrists documented recent suicidal ideation and unstable mental state but determined he was not actively sui…
27y · Male·propoxyphene toxicity
A 27-year-old man with schizophrenia died of propoxyphene toxicity while in police custody. He ingested a fatal dose of Doloxene capsules prescribed by Dr R. on 27 June 2000. The doctor prescribed 100 capsules to a patie…
43y · Female·neck compression due to hanging
A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…
67y · Male·Aspiration of vomit associated with alcohol intoxication in a man with ischaemic…
Eric Clarence Moody, a 67-year-old man with diabetes, chronic alcoholism, and ischaemic heart disease, died on 6 December 1999 after aspirating vomit while heavily intoxicated with methylated spirits. He presented to Nor…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
38y · Female·mixed drug toxicity (lethal level of dothiepin, potentially lethal level of morp…
A 38-year-old woman with long-standing heroin and benzodiazepine dependence died from mixed drug toxicity following injection of heroin. Her GP had prescribed multiple benzodiazepines (diazepam, oxazepam, temazepam) and …
17y · Female·mixed drug toxicity
Nicole Davies, aged 17, died from mixed drug toxicity after rapid methadone dose escalation combined with multiple CNS depressants. She presented to Dr Turner requesting methadone maintenance on 23 March 2000 with undisc…
17y · Female·mixed drug toxicity
Nicole Davies, 17, died from mixed drug toxicity after rapid methadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet receiv…
88y · Female·sepsis of unknown origin
An 88-year-old woman with multi-infarct dementia and behavioural disturbance was detained under the Mental Health Act following assault of her GP. She presented with abdominal symptoms and deteriorating vital signs, tran…
56y · Female·subarachnoid haemorrhage complicating berry aneurysm of the right middle cerebra…
Margaret Joyce Taylor, aged 56, died from subarachnoid haemorrhage due to rupture of a berry aneurysm on the right middle cerebral artery. She presented to three medical practitioners over 6 days with progressive occipit…
47y · Male·neck compression due to hanging
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…
25y · Male·coronary thrombosis resulting from coronary atherosclerosis
A 25-year-old Aboriginal man with undiagnosed coronary artery disease collapsed and died one hour after a consultation at an Aboriginal health clinic. The coroner found the medical examination by Dr M. was inadequate and…
67y · Female·bronchopneumonia complicating disseminated pulmonary large cell carcinoma with r…
Nancy McCarthy, 67, presented with progressive back and chest pain initially attributed to vertebral compression fracture. She deteriorated acutely with confusion, agitation, and respiratory distress, necessitating Menta…
26y · Male·.357 magnum gunshot wounds to the chest and abdomen
Luke Donaghey, a 26-year-old man with untreated psychotic illness, was shot by police after threatening his parents with a knife. Critical clinical lesson: his general practitioner failed to utilize available mental heal…
27y · Female·Aspiration of gastric contents associated with persistent vomiting following gas…
A 27-year-old woman died from aspiration of gastric contents following a vertical-banded gastroplasty performed for morbid obesity. The surgeon created a stoma (opening) of 4-5mm diameter using a 27 French bougie, smalle…
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