1,648 results
<1y · Female·Sudden unexpected death in an infant (SUDI) in an unsafe sleeping environment
This is a SUDI death of a 42-day-old Aboriginal infant who died in an unsafe sleeping environment due to co-sleeping with her mother on a single mattress in an overcrowded unit. The mother, a 21-year-old with complex tra…
28y · Male·Hypoglycaemia due to administration of exogenous insulin
Mitchell Johns, 28, died from hypoglycaemia following an intentional insulin overdose during a suicide attempt. He had Type 1 diabetes, depression, and chronic suicidal ideation. On 27 May 2021, he presented to Bendigo H…
46y · Female·Pulmonary embolism (saddle embolus in pulmonary trunk)
Kate Manley, 46, died from a pulmonary embolism while an inpatient at Albury Base Hospital receiving psychiatric care for catatonia. She was not prescribed prophylactic anticoagulation despite risk factors including immo…
70y · Female·Ruptured abdominal aortic aneurysm
Ms Honey was a 70-year-old woman admitted involuntarily to a mental health facility with acute psychosis. Six days before her death, an 8cm abdominal aortic aneurysm (AAA) was discovered incidentally on imaging, with vas…
40y · Male·Carbon monoxide toxicity
Paul Shen Vun Wong, a 40-year-old man with treatment-resistant schizophrenia and schizoaffective disorder, died from carbon monoxide toxicity at his Rockingham home in April 2023 while subject to a Community Treatment Or…
69y · Female·Exacerbation of chronic obstructive pulmonary disease and ischaemic heart diseas…
Lynette McHarry, aged 69, died on 15 August 2024 at Casey Hospital following complications from a preventable medication error at Mooraleigh Hostel residential aged care facility. On 4 August, she was mistakenly administ…
32y · Male·multiple injuries
Travis Walder, 32, died by suicide on 24 August 2023 after being struck by a train. He had schizophrenia and opioid use disorder with prior suicide attempts. On 23 August, he became acutely agitated and psychotic at his …
37y · Male·Multiple injuries sustained in a train incident
A 37-year-old Aboriginal man with chronic opioid use disorder and co-occurring mental health issues presented to Royal Melbourne Hospital's Mental Health, Alcohol and Other Drugs Hub after being found slumped in Melbourn…
44y · Male·Neck compression; Hanging
Andre Alistair Hei, a 44-year-old Māori man, died by suicide via hanging on 11 March 2025 at Fitzroy Town Hall. He had a complex psychiatric history including depression, complex PTSD, methamphetamine use disorder, and c…
Male·ligature compression of the neck (hanging)
Kyen Tollett, remanded at Casuarina Prison, died by hanging on 10 October 2024. He had a well-documented history of relationship-triggered suicidality and received high-quality psychiatric care and counselling throughout…
62y · Male·complications of chronic alcohol misuse and olanzapine toxicity
John Aramathuparambil John, a 62-year-old with chronic alcohol dependence and depression, was arrested for trespass following a confused intrusion into a home on 6 June 2023. Police noted confusion and apparent intoxicat…
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…
23y · Male·Plastic bag asphyxia
GRA was a 23-year-old who died by suicide on 13 August 2024. He had depression, anxiety, and suicidal ideation since age 21. The mental health team (HOPE) discharged him in April 2023 when thoughts improved, recommending…
32y · Male·Hanging (deliberately self-inflicted)
Fredrick Elrezz, 32, died by hanging in segregation at Parklea Correctional Centre on 25 September 2020. Arrested on 1-2 September after stabbing police in an apparent suicide-by-cop attempt, Fred explicitly stated his i…
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 …
34y · Male·multiple gunshot wounds
SK, age 34, died on 10 January 2024 after being shot 12 times by NSW Police tactical officers at a medical practice in Nowra. He had chronic schizophrenia, opioid dependence, and was experiencing active psychosis. His GP…
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…
52y · Male·Gunshot wound to the chest
Steven Richard Angus, a 52-year-old veteran with severe alcohol use disorder, major depressive disorder, and generalised anxiety disorder, died from a gunshot wound inflicted by Queensland Police during a welfare check o…
42y · Male·Gunshot injury to the head
AT was a 42-year-old secondary school teacher with diagnosed depression, adjustment disorder, and ketamine abuse beginning in 2019. He received inpatient psychiatric treatment in August 2021. On 20 December 2024, followi…
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
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