796 results
Male·Unascertained (fatal injuries from vehicle crash and/or thermal effects of bushf…
Four people died in a catastrophic bushfire near Scaddan, Western Australia in November 2015 while attempting to evacuate. Kym Curnow, a local farmer and volunteer firefighter, was driving his own vehicle, while Tom Butc…
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
76y · Male·Sepsis due to pulmonary valve endocarditis and cardiac abscess due to Staphyloco…
A 76-year-old man died from sepsis caused by Staphylococcus aureus endocarditis and cardiac abscess. An intravenous cannula inserted during day surgery on 29 November 2018 was not removed before discharge, despite hospit…
49y · Male·multiple injuries
A 49-year-old remand prisoner died from multiple injuries after being pinned between a reversing truck and a coolroom wall in the prison industries yard. The deceased voluntarily offered to guide the truck as it reversed…
<1y · Male·Head injury in the setting of labour
Finn Moser was a one-day-old neonate who died from head injury sustained during labour and delivery at the Royal Women's Hospital. He was born to a mother with dichorionic diamniotic twins, induced at 36 weeks due to pre…
Unknown·MDMA toxicity (one case mixed MDMA and cocaine toxicity)
This inquest examined six deaths from MDMA toxicity after electronic dance music festivals in NSW between December 2017 and January 2019: Hoang Nathan Tran (18), Diana Nguyen (21), Joseph Pham (23), Callum Brosnan (19), …
71y · Female·pneumonia following cervical spine fracture sustained in motor vehicle collision
Julie Anne Holmes, aged 71, died of pneumonia following a cervical spine fracture sustained in a motor vehicle accident that was not diagnosed during her hospital admission. Critical clinical lessons include: (1) paramed…
49y · Male·drowning combined with head trauma
Eric Fillisch, an experienced 49-year-old rebreather diver, died from drowning following head trauma sustained in an underwater cave at Visscher Island, Tasmania. While exploring a fissure cave after his dive partner sur…
63y · Male·Chest injuries
Trevor O'Brien, aged 63, died from chest injuries sustained while performing DIY maintenance on his caravan. He improperly used the caravan's jockey-wheel as a vehicle jack to support the vehicle's weight while working u…
27y · Female·chest injuries
Olivia Inglis, 27, died from chest injuries sustained in a fall whilst competing in the cross country phase of eventing at the 2016 Scone Horse Trials. She successfully negotiated fence 8A but fell at fence 8B. The coron…
30y · Male·ligature compression of the neck (hanging)
Paul Strange, aged 30, died by suicide through ligature compression of the neck eleven days after discharge from Royal Perth Hospital (RPH) for depression with chronic suicidality. He had a documented history of multiple…
87y · Female·Natural causes in the context of multiple co-morbidities including a sacral ulce…
87-year-old woman died in aged care with a stage 4 sacral ulcer and multiple comorbidities. Key clinical lessons: (1) Systematic communication failures—family was not informed that a healed sacral wound re-emerged in Mar…
Female·Head injury in the setting of an obstructed labour
A term-destined baby (35 weeks gestation) died from head injuries sustained during delivery. She presented to hospital with suspected preterm labour, was managed conservatively initially, and progressed to spontaneous la…
40y · Male·drowning
Graeme Bowerman drowned following the capsize of a recreational fishing boat in Marion Bay, Tasmania. The skipper, Mr Marriott, misjudged sea conditions and navigated into an active 3-metre swell in a surf break despite …
51y · Male·Sepsis due to or as a consequence of right lower limb necrotising fasciitis due …
A 51-year-old man with metastatic renal cell carcinoma died from sepsis following necrotising fasciitis of the lower limb, which developed after a pseudo-aneurysm complication from coronary angiography. Key clinical less…
Male·Drowning (confirmed for Luke Davies and Magnus Ritter; suspected but unproven fo…
Four young men drowned when their recreational fishing boat sank in Frederick Henry Bay on 31 July 2016. None held motor boat licenses despite this being a legal requirement. The boat was a 50-year-old fibreglass vessel …
Unknown·FV Cassandra: vessel capsize likely whilst retrieving snagged trawl net from sea…
Joint inquest into eight fishermen lost at sea from FV Cassandra (2016, two deceased) and FV Dianne (2017, six deceased). FV Cassandra capsized while attempting to retrieve snagged trawl net caught on seabed reef; likely…
8y · Female·complications of multiple injuries sustained in motor vehicle crash
Eight-year-old Anita Board died from catastrophic brain injury sustained in a motor vehicle crash at Perth Motorplex on her first junior drag racing licensing attempt. Her dragster failed to slow adequately after the fin…
57y · Male·Abnormal cardiac arrhythmia due to electric shock; contributing cause: coronary …
Stephen Leonard Viner, a 57-year-old handyman, died from an abnormal cardiac arrhythmia triggered by electrical shock while investigating a failed sump pump in a flooded basement. He turned on an isolator switch to a sup…
53y · Female·multiple organ failure as a result of septic shock
Pauline Kessell, aged 53, died from septic shock caused by overwhelming sepsis following endoscopic pyeloscopy with laser lithotripsy for a 5cm infected staghorn calculus on 12 August 2015. Critical clinical lessons: (1)…
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