69 results
Unknown·Choking; Mr Gesios: large bolus of bread and scrambled eggs causing complete air…
Two aged care residents died from choking on bread despite being prescribed minced and moist diets that prohibited regular bread. Mr Gesios was fed bread dipped in Milo by an inexperienced AIN without adequate supervisio…
39y · Male·Mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) with contribut…
Kevin Thomas Maloney, a 39-year-old man with complex mental health conditions and substance use disorder, died from mixed drug toxicity (heroin, venlafaxine, alprazolam, pregabalin) while residing in a supported resident…
2y · Male·cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn, a healthy 2 year 8 month old boy, died from cardiorespiratory arrest due to opioid (morphine) toxicity following an elective circumcision procedure performed under sedation in a general practice setting on 7…
19y · Male·fatal gunshot wounds to the chest and back from three rounds fired by Constable …
Kumanjayi Walker, a 19-year-old Warlpiri/Luritja man with complex trauma history, was fatally shot three times on 9 November 2019 during an attempted arrest in Yuendumu. The coroner found the death was avoidable and resu…
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
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…
43y · Female·asphyxia due to hanging
Helen Bird, aged 43, was found hanging in her garage in July 2010. While initially ruled suicide, a reopened coronial investigation found the coroner believes she was killed by her husband Mark Bird. Evidence showed Hele…
79y · Female·Chronic obstructive pulmonary disease
Jean Alice Dowson, 79, died in an aged care facility after being commenced on end-of-life medications. She had severe COPD and was frail (29kg). On 10 April 2017, when she deteriorated with respiratory distress, a Clinic…
5y · Male·Septic shock due to Influenza A infection and bacterial co-infection with Staphy…
A 5-year-old boy died from septic shock complicating influenza A with bacterial co-infection (Staphylococcus aureus or Group A Streptococcus). He presented to the ED on 22 May 2022 with fever, abdominal pain, and vomitin…
87y · Male·Combined effects of sotalol toxicity on a background of severe valvular and athe…
An 87-year-old man with Alzheimer's disease died in a residential aged care facility after ingesting Sotalol, a cardiac medication not prescribed to him. The medication trolley was left unlocked and accessible despite fa…
64y · Male·hypoxic-ischaemic encephalopathy and its complications following cardiac arrest …
Christopher Lens, a 64-year-old man with schizophrenia under guardianship at a nursing home, died from hypoxic-ischaemic encephalopathy following cardiac arrest due to upper airway obstruction after choking on a peanut b…
76y · Male·Bronchopneumonia with multiple organ failure in the setting of advanced metastat…
John Henry Waterfall, a 76-year-old prisoner at Acacia Prison, died from bronchopneumonia with multiple organ failure secondary to advanced metastatic prostate cancer. He received generally appropriate medical care durin…
84y · Female·pneumonia and fracture of the neck of right femur following a fall
Mrs Bell, aged 84, died from pneumonia and a fractured right femoral neck sustained in a fall at a residential aged care facility. She had advanced Alzheimer's disease, cognitive impairment, impulsive behaviour, and was …
Female·Betty: cardiac arrhythmia complicating heart failure due to consequences of past…
This inquest examined three deaths of young Aboriginal women from Doomadgee (ages 18, 37, and 17) from rheumatic heart disease (RHD) complications between September 2019 and September 2020. All three deaths were preventa…
11y · Female·Complications of E. coli sepsis in association with intestinal obstruction due t…
Child R, an 11-year-old Aboriginal girl with congenital anorectal anomalies causing chronic severe constipation, presented to Halls Creek Hospital on 5 January 2017 with severe abdominal pain and vomiting. She died 12 ho…
31y · Female·Plastic bag asphyxia
31-year-old Veronika Kouros, a voluntary inpatient at Northern Psychiatry Unit with bipolar affective disorder, obsessive-compulsive disorder, and depression, died by plastic bag asphyxia on 19 March 2018. Despite hospit…
63y · Female·Complications following sedation for percutaneous endoscopic gastrostomy (PEG) t…
Dianne Linford, a 63-year-old woman with profound disability from cerebral palsy and encephalitis, died from complications of sedation for PEG tube insertion. She had a congenital polymicrogyria, a significant neurologic…
87y · Male·Metastatic carcinoma of the prostate with complications (end-of-life palliative …
Errol Warren Bartlett-Torr, aged 87, died of metastatic prostate cancer on 20 June 2021 whilst in prison custody and receiving palliative care at Bethesda Hospital. Clinical lessons include: (1) elevated PSA findings sho…
70y · Female·Cause of death could not be determined - available evidence does not allow a fin…
A 70-year-old woman died unexpectedly at home in August 2017. Initially certified as hypertensive heart disease without autopsy, the death was later investigated as a potential homicide following allegations by her forme…
91y · Male·Complications of cerebrovascular and ischaemic heart disease in a man post anaph…
A 91-year-old man with known diltiazem allergy was prescribed diltiazem by a geriatrician despite documented allergy records. The geriatrician relied on the patient's verbal denial of allergies despite significant dement…
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