17y · Male·cranial and facial trauma
A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic episode. Hours before, he had been seen by a trainee psychologist who failed to reco…
17y · Female·mixed drug toxicity
Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…
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, 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…
26y · Male·Ligature compression of the neck (Hanging)
Scott Davidson, a 26-year-old recently sentenced prisoner with paranoid schizophrenia, died by suicide in Casuarina Prison on 5 June 2000. Following sentencing to 9 years imprisonment, he was transferred to Casuarina Pri…
26y · Female·cardiorespiratory arrest due to massive gastric dilatation with gastric rupture
Assunta Petroccia, a 26-year-old woman, died from cardiorespiratory arrest due to massive gastric dilatation with rupture following a bulimic episode. She presented to hospital with severe abdominal pain and was incorrec…
30y · Female·respiratory failure related to bronchopneumonia following cerebral anoxia due to…
A 30-year-old woman with a previous caesarean section attempted a trial of vaginal delivery. She received Syntocinon augmentation at 6:45 AM without prior cervical assessment and epidural analgesia at 7:35 AM. No vaginal…
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 (…
15y · Male·compression of the neck by hanging
A 15-year-old Aboriginal male, Johnno Wurramarrba, from Groote Eylandt died by hanging in Don Dale Juvenile Detention Centre on 10 February 2000, while serving a 28-day sentence for property offences. Key preventable fac…
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…
7y · Female·Multiple abdominal injuries including traumatic rupture of the liver and stomach…
A 7-year-old girl died from massive abdominal injuries sustained when a car, driven by an insulin-dependent diabetic man, collided with a group of pedestrians. The driver had undiagnosed and unaware hypoglycemia at the t…
82y · Female·peritonitis due to a perforated viscus (proximal jejunum) resulting from motor v…
An 82-year-old woman suffered a motor vehicle accident causing blunt abdominal trauma. Despite initial clinical assessment appearing adequate, a perforated jejunum with developing peritonitis was not diagnosed until earl…
33y · Male·carbon monoxide poisoning consistent with inhalation of car exhaust fumes
A 33-year-old man with major depressive disorder and multiple suicide attempts died by carbon monoxide poisoning after premature discharge from psychiatric inpatient care. He was admitted to Lyell McEwin Health Service o…
45y · Female·haemorrhage due to traumatic rupture of the liver
A 45-year-old woman with a long history of bipolar disorder and personality disorder presented to the ED at 2:30 AM after cutting her wrist deeply with a carving knife. The treating casualty officer did not properly docu…
26y · Male·Closed head injury with extradural and subdural haemorrhage resulting from a sku…
26-year-old Marcio Jose Lay Nheu died from a closed head injury with extradural haemorrhage caused by a blow to the head with a Maglite torch at Karama Shopping Centre. He was struck by Rodney Foster during an altercatio…
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…
28y · Male·asphyxiation following severe swelling to the larynx due to anaphylactoid reacti…
A 28-year-old Aboriginal male died from anaphylactoid reaction to Haemaccel, a plasma volume expander administered pre-hospital following a severe laceration to the radial artery. Initial management was appropriate, but …
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