795 results
Unknown·Thomas Wolfram Spiess: head, neck and chest injuries; Jacqueline Byrne: multiple…
On 18 August 2014, a 14-tonne effluent truck lost control on South Eastern Freeway's steep downhill section and struck multiple vehicles at high speed, killing Thomas Spiess (aged 56) and Jacqueline Byrne (aged 41). Spie…
47y · Female·head injury
Sohaila Mohammadi (47) was killed in a motor vehicle collision caused by driver Tristan Mourant, who had bilateral retinal dystrophy and was advised by three medical professionals not to drive. However, none of the docto…
70y · Male·metastatic gastric adenocarcinoma
A 70-year-old man with prior bladder cancer was undergoing routine CT surveillance. Stomach cancer signs were clearly visible on February 2017 and February 2018 CT scans but failed to be detected by consulting radiologis…
Male·toxicity caused by a combination of methylamphetamine and morphine
Felipe Esteban Alvarez died on 30 March 2021 from toxicity caused by methylamphetamine and morphine (heroin) ingestion at his unit in Taylor, ACT. He collapsed after self-injecting heroin in the presence of others, inclu…
69y · Female·Head and chest injuries sustained in a fall from a height during a climbing inci…
Lee Lee Heah, aged 69, died on 19 November 2024 from head and chest injuries sustained in a fall of approximately 8 metres while traditional rock climbing at Mount Arapiles, Victoria. An experienced adventure climber, sh…
34y · Male·Hanging
BS, a 34-year-old man with PTSD and depression from previous custodial assault, was remanded on drug importation charges at MRRC during COVID-19 restrictions. Critical clinical failures included: (1) 118-day delay in psy…
61y · Male·Exsanguination from sharp force injuries to both arms, dissecting the veins of t…
CG, aged 61, died in Parklea Correctional Centre on 18 May 2024 from hemorrhage due to self-inflicted sharp force injuries. The coroner found multiple clinical and system failures contributed substantially to the death. …
67y · Male·Multi-organ failure secondary to acute myocardial infarction secondary to in-ste…
Christopher Doughty, 67, was admitted to Hervey Bay Hospital on 17 September 2021 with a life-threatening gastrointestinal bleed two months after receiving coronary stents. The bleed was likely caused by dual antiplatele…
56y · Male·Drowning in the setting of scuba diving
Earl Allen Blessing Jr., 56, died while scuba diving alone in Port Phillip Bay near Rye Pier on 3 February 2024. The coroner found he drowned after running out of air during his dive, having either entered the water with…
<1y · Male·traumatic head injury due to instrumental vaginal delivery of a term infant
Baby H died on 24 March 2019, one day after birth, from traumatic head injuries sustained during an instrumental vaginal delivery using Neville Barnes forceps on a baby in occipito-posterior position. Critical clinical l…
Male·phosphine toxicity in a man with atherosclerotic heart disease
Robert Lavars died on 6 September 2022 after deliberately ingesting aluminium phosphide tablets while under police arrest at his home in Shoalwater. He had serious health conditions including strokes, heart disease, and …
68y · Male·Cardiac arrest - unascertained etiology with multiple contributing factors inclu…
Wayne Thomas Kerle, 68, was arrested at his home for cannabis possession. Queensland Ambulance Service paramedics assessed him when he reported respiratory distress but cleared him for police custody after a limited exam…
23y · Female·Methylamphetamine toxicity
Patience Kuzmins, 23, died in custody at Silverwater Women's Correctional Centre on 10 November 2022 from methylamphetamine toxicity caused by an internally concealed package. The coroner found that Patience was not stri…
17y · Male·Suicide by self-inflicted hanging
RL was a 17-year-old Alice Springs teenager who died by suicide while under Northern Territory mental health services' care. Critical clinical lessons emerged: failure to inform his mother about mental health deteriorati…
74y · Male·Probable respiratory failure in a man with advanced motor neurone disease in the…
Philip McHardy, a 74-year-old man with advanced motor neurone disease (MND), died of respiratory failure on 13 July 2025 after a five-month hospital admission. He was dependent on non-invasive ventilation (NIV) for up to…
87y · Female·Oesophageal perforation following an elective oesophageal dilatation, secondary …
87-year-old Helen Mahlis died from oesophageal perforation following an elective balloon dilation procedure at Epworth Richmond for treatment of achalasia. The coroner identified two contributing factors: use of a 35mm b…
29y · Male·Cardiac arrhythmia in the context of alcohol withdrawal and chronic alcohol misu…
A 29-year-old man died from cardiac arrhythmia in the context of severe alcohol withdrawal at a correctional facility. Initial assessment correctly identified moderate-to-severe withdrawal (AWS score 8) with seizure hist…
62y · Female·Acute bacterial peritonitis and pneumonia
Rosemarie Campbell, 62, died 27 February 2022 from acute bacterial peritonitis and pneumonia following a Roux-en-Y gastric bypass at Wesley Hospital. Pre-operative failures: The surgeon inadequately investigated her refl…
Unknown·Nicholas Brown: combined drug (methadone and benzodiazepine) intoxication; Toni …
Joint inquest into four deaths of individuals prescribed opioid replacement therapy by Dr J. between September 2016 and August 2017: Nicholas Shane Brown (35), Toni Lee Wiki (38), Matthew Wayne Winwood (47), and Belinda …
<1y · Male·Perinatal hypoxia
Baby R, born at 39 weeks 6 days via planned homebirth with private midwives, died from perinatal hypoxia on day 6 of life. The mother had significant obstetric risk factors: previous emergency caesarean section, macrosom…
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