84 results
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…
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…
<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 …
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…
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…
61y · Male·Ischaemic heart disease secondary to coronary artery atherosclerosis
AQ, a 61-year-old motorsport racer, died from ischaemic heart disease secondary to coronary artery atherosclerosis while competing at Phillip Island Grand Prix Circuit on 23 November 2024. In April 2024, he underwent ste…
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 was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…
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…
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…
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