17 results
50y · Female·hanging
A 50-year-old woman with severe borderline personality disorder and ADHD died by hanging in immigration detention. The coroner found her mental health monitoring and treatment were adequate, though she received only two …
47y · Male·ligature compression of the neck (hanging)
A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which wer…
19y · Male·Electrocution
Ali El-Sayed, a 19-year-old apprentice electrician, was electrocuted while connecting an air conditioning unit to power without isolating the electrical supply. He was directed by a non-qualified site manager (family mem…
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
Male·Unrecognised pulmonary hypertension in a setting of unsafe sleeping conditions
Jack Loh, a 6-month-old boy, died from unrecognised pulmonary hypertension while in unsafe sleeping conditions at a family day care centre. Jack was placed prone (face down) in an undersized bassinet with loose bedding m…
40y · Male·Penetrating wounds to the chest
Scott William Martin, aged 40, was fatally stabbed in his apartment in Halls Head, Western Australia in January 2017 by Damian Maxfield, who was experiencing a methamphetamine-induced psychotic episode. Maxfield had been…
3y · Female·tramadol toxicity
A 3-year-old girl in state care died from tramadol toxicity after accessing prescribed opioid medication left unsecured in her carer's bedroom. The child was removed from her mother's care due to neglect and substance ab…
25y · Male·Injuries sustained when struck by a train (suicide)
Damon Brenden Amiet, a 25-year-old with schizoaffective disorder, borderline personality disorder, and antisocial personality traits, was admitted to a psychiatric inpatient unit (IPU1) on 12 April 2013 following a serio…
28y · Male·Neck compression consistent with hanging
A 28-year-old man with severe depression, persistent suicidal ideation and previous suicide attempts died by hanging in a mental health inpatient unit while under involuntary detention. Despite being assessed as high sui…
53y · Female·hanging
Maria Nigro, a 53-year-old woman with depression and recent medication overdose, was admitted involuntarily to Werribee Mercy Hospital's Low Dependency Unit (LDU) on 4 February 2009. Despite a risk assessment on 9 Februa…
31y · Male·Chest injuries (principal cause) with autism and epilepsy as underlying causes
Stuart Lambert, a 31-year-old man with cerebral palsy, autism, and epilepsy, died from chest injuries sustained at his carer's semi-rural residence. He collapsed during or after a seizure and experienced multiple rib fra…
90y · Female·Renal failure secondary to gentamicin therapy for urinary tract infection (sepsi…
Ellen O'Connor, a 90-year-old woman with renal artery stenosis and coronary artery disease, died from acute renal failure following gentamicin administration for Pseudomonas aeruginosa urinary tract infection. A single 2…
78y · Female·Severe burns sustained while smoking
A 78-year-old woman with dementia and significant manual dexterity deficits suffered fatal burns while smoking unsupervised in an aged care facility. Despite documented cognitive impairment and physical limitations preve…
34y · Male·hypoxic encephalopathy following hanging
Daniel O'Keeffe, a 34-year-old male with amphetamine abuse and depression, died from hypoxic encephalopathy following hanging in Adelaide Remand Centre on 7 February 2007. He had attempted self-harm twice in custody afte…
70y · Male·Acute coronary occlusion due to extensive coronary atherosclerosis
Kenneth Maggable, a 70-year-old man with chronic obstructive pulmonary disease, asthma, and prostate cancer, presented twice to Cairns Base Hospital on 8 August 2005 with respiratory complaints. After discharge at 4:50 A…
16y · Female·Adrenal insufficiency (Addison's Disease)
Emma Louise Robson, a 16-year-old female, died on 29 September 2004 from adrenal insufficiency (Addison's Disease), a treatable autoimmune condition. She presented with progressive fatigue, weight loss (from 48–50 kg to …
29y · Male·electrocution
Scott Robert Grimley, a 29-year-old qualified electrical fitter/mechanic, died from electrocution on 21 January 1998 while working on overhead power lines from an elevated work platform. The coroner found that although G…
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