1,733 results
20y · Male·Drowning precipitated by a seizure
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax
A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
50y · Male·Unascertained
A 50-year-old homeless man from South Sudan was found deceased in a disused office space at a car wrecking workshop in Braybrook, Victoria. He had been medically obese with an unhealthy lifestyle including alcohol consum…
76y · Male·Extensive small bowel infarction caused by superior mesenteric artery thrombus
A 76-year-old man presented to ED with sudden onset left-sided abdominal pain, vomiting and bowel incontinence. Initial CT imaging was reassuring. However, mesenteric ischaemia—characterised by severe pain without signif…
47y · Female·hyponatraemia arising from primary polydipsia and complications of schizoaffecti…
Tammy Michelle Shipley, a 47-year-old Aboriginal woman with chronic schizoaffective disorder and bipolar disorder, died in custody on 20 December 2022 from hyponatraemia arising from primary polydipsia. She was arrested …
39y · Male·Effects of fire (self-immolation)
William Gourley, a 39-year-old Aboriginal and Torres Strait Islander man with a long history of mental illness, depression, cannabis dependence, and psychosis, presented to the Latrobe Regional Hospital ED on 6 March 202…
25y · Female·Neck compression secondary to hanging
CM, a 25-year-old woman experiencing depression, anxiety, and substance misuse, died by suicide while in an intimate partner relationship characterised by documented family violence. She presented to hospital multiple ti…
55y · Male·Diabetic ketoacidosis
CM, a 55-year-old man with severe congenital disabilities and Type 2 Diabetes, died from diabetic ketoacidosis while residing in a disability support facility. In the week preceding death, he experienced reduced appetite…
68y · Female·Acute myocardial infarction and coronary artery atherosclerosis
A 68-year-old woman presented to St Vincent's Hospital emergency department with upper abdominal and left-sided chest pain following a stationary bicycle fall. Clinicians attributed her symptoms to codeine adverse reacti…
54y · Female·neck compression secondary to hanging
Ms NXA, a 54-year-old woman with complex mental health conditions including depression, CPTSD, and anxiety, presented to hospital after a suicide attempt by overdose on 9 August 2021. She was experiencing severe tinnitus…
68y · Male·bronchopneumonia in a man with carcinoma in the lung and chronic obstructive pul…
Frank Mikhail, a 68-year-old prisoner with severe COPD, presented to St John of God Hospital on 29 January 2023 with haemoptysis and was discharged without admission. Critical clinical lessons include: (1) haemoptysis in…
35y · Male·multi-drug toxicity
CPL Ian Turner, a 35-year-old Special Forces soldier with combat-related PTSD, died from multi-drug toxicity in July 2017. His death followed multiple deployments to Afghanistan and Iraq, domestic violence incidents, dis…
23y · Male·Drowning
Stephen John Burt, aged 23, was found deceased in January 1985, with drowning as the cause. His remains were unidentified for 36 years until 2021. Critical failures included: catastrophic incorrect sequencing of fingerpr…
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.