1,172 results
53y · Male·Neck compression in the circumstances of hanging
A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
22y · Male·Neck compression by ligature suspension (hanging)
A 22-year-old international student from India died by hanging at his home in Victoria. He was studying information technology at Monash University after experiencing academic difficulties, having failed multiple subject…
66y · Female·aspiration pneumonitis and gangrenous necrosis of both feet
A 66-year-old woman with untreated rheumatoid arthritis, severe lower limb cellulitis with gangrenous necrosis, and a personality disorder died from aspiration pneumonitis. She had progressive immobility, lived on a couc…
73y · Male·Complications of metastatic neuroendocrine lung carcinoma
John O'Donnell, aged 73, died in custody from complications of metastatic neuroendocrine lung cancer while hospitalised at Westmead Hospital. The coroner identified two systemic issues during his brief incarceration at S…
64y · Male·Complications of eosinophilic asthma with bronchiectasis and allergic bronchopul…
Wayne Mullin, a 64-year-old man with severe eosinophilic asthma, bronchiectasis, and allergic bronchopulmonary aspergillosis, died between 21 September and 20 October 2021. Toxicology revealed oxycodone and diazepam at l…
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…
30y · Male·Gunshot wound to the neck and head
Daniel Bolton, aged 30, died from a self-inflicted gunshot wound to the neck and head while attempting to avoid arrest by police. He had a history of drug addiction, mental health issues including depression, anxiety and…
86y · Male·carbon monoxide poisoning
An 86-year-old man with recent stroke, declining mental health, and expressed suicidal ideation died by carbon monoxide poisoning. He was assessed in hospital ED, deemed not to meet Mental Health Act criteria, and discha…
15y · Male·Hanging
A 15-year-old Aboriginal boy with complex trauma history, including physical abuse, parental mental illness, and 40+ child protection reports, disclosed a suicide attempt to his school counsellor in December 2019. A mand…
27y · Male·Injuries sustained in motor vehicle collision (driver)
Jackson Eales, 27, died in a motor vehicle collision at an intersection when truck driver Gerard Voss failed to stop at a stop sign in December 2016. The coroner found it highly probable Voss had undiagnosed severe obstr…
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
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 …
43y · Female·Complications of obesity including cardiomegaly
Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disability services group ho…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…
27y · Male·Hanging
Marcus Caldwell, a 27-year-old with well-controlled schizophrenia on clozapine, died by suicide in February 2018. He worked at a pet boarding facility that experienced severe staffing shortages during peak season, result…
31y · Male·Hanging
Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …
75y · Female·Renal failure and ketoacidosis in a woman with chronic alcoholism and type 2 dia…
A 75-year-old woman with type 2 diabetes and chronic alcoholism died from renal failure and ketoacidosis at home. She was isolated, dependent on her elderly husband for care, and living in squalor. Over 20 disclosures of…
27y · Female·carbon monoxide intoxication due to voluntary and intentional inhalation of exha…
A 27-year-old woman with a lengthy history of depression, anxiety, and previous suicide attempts died by carbon monoxide poisoning. She was referred to mental health crisis services on 4 July 2020 with documented suicida…
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