113 results
0y · Male·Traumatic head injury
A five-month-old boy died from traumatic head injury. Initial medical disagreement about whether injuries were from accidental fall or non-accidental trauma delayed investigation. The child presented with extensive bruis…
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…
47y · Male·Multiple injuries due to or as a consequence of a motor vehicle accident
Trevor Toms, 47, died in a head-on motor vehicle collision after driving at speed on the wrong side of a rural highway. He had epilepsy managed with sodium valproate but had experienced multiple seizures in the months be…
48y · Female·Combined drug toxicity involving oxycodone, benzodiazepines (diazepam, nordiazep…
A 48-year-old woman with epilepsy, depression, anxiety and documented drug dependence died from combined toxicity of oxycodone, benzodiazepines, amitriptyline and other drugs. Over 12 months pre-death, she obtained medic…
41y · Male·Subdural haematoma
A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
53y · Male·Bilateral ACA stroke
A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and delays in stroke team referral, he was …
55y · Male·Complications of right middle cerebral artery infarction
Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symp…
48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam
A 48-year-old woman died from ischaemic brain injury caused by overdose of tramadol and temazepam. She was found unresponsive at home on 10 October 2009 after consuming these medications. Her family and GP Dr Dixit faile…
24y · Female·peri-myocarditis in the presence of sub clinical Addison's disease
Jessica Martin, 24 years old, died of peri-myocarditis in the presence of subclinical Addison's disease. She presented to the ED with chest pain on 30 June 2009 and was diagnosed with viral pleurisy without specific inve…
78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…
Paul Henri, 78, died from cerebral infarction and hypoxic brain damage following aspiration pneumonia and opioid-related complications. He was admitted to an aged care home and commenced on MS Contin (morphine) 30mg dail…
51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …
John Spence, a 51-year-old man with a history of seizures, alcoholism, and severe coronary artery disease, died in a prison health centre following a seizure episode. He had ingested an extraordinarily high level of caff…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
69y · Female·Asphyxiation consistent with hanging
A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…
44y · Female·Unascertained
A 44-year-old woman with chronic pain, epilepsy, and opioid dependence died at home with an unascertained cause in the setting of prescription medication use. She was a known 'doctor shopper' who obtained opioids from mu…
3y · Female·Homicide by chloroform exposure and/or smothering by father
Divya Sharma, age 3, died in April 2012 in Glen Waverley, Victoria, as part of a family homicide-suicide perpetrated by her father. The coroner found she was likely killed by chloroform exposure and smothering between 28…
35y · Female·homicide by smothering/suffocation, possibly facilitated by chloroform exposure
This tragedy involved the deaths of Preetika Sharma (35), her two children (Divesh, 5; Divya, 3), and her husband Nilesh, who killed his family and then himself. Mr Sharma exposed family members to chloroform before smot…
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…
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