4,457 results
31y · Male·Head injuries - horse rider struck by a motor vehicle
A 31-year-old Japanese horse rider died from head injuries after being struck by a motor vehicle while crossing a public road with horses at dawn. Low light conditions (approximately 6:40 am, still dark) impeded the driv…
40y · Female·Stab wounds to the chest and abdomen
A 40-year-old woman was fatally stabbed by her former intimate partner who had an extensive history of family violence offending and multiple breaching intervention orders. Despite multiple service contacts in the days b…
57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)
Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…
59y · Male·Shotgun wound to the head
A 59-year-old man with a work-related shoulder injury developed anxiety and depression, later expressing suicidal ideation during mental health treatment. His general practitioners and psychologist provided appropriate m…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…
49y · Male·undetermined
A 49-year-old man with paranoid schizophrenia on clozapine became non-compliant with mental health appointments in July 2021. After threatening clinic staff while acutely psychotic, mental health services and police atte…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: acceptin…
40y · Male·hypothermia
Nathan Booth, a 40-year-old Aboriginal man with opioid addiction, was reported missing on 2 September 2019 after last being seen on 27 June 2019 when he obtained his methadone dose at Canberra Hospital. His body was foun…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…
A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
50; 37y · Male; 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…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
22y · Male·Gunshot wounds to the torso (Raghe Abdi); Multiple blunt and sharp force injurie…
This inquest examined three deaths: elderly couple Maurice (87) and Zoe Antill (86) who were stabbed to death at their home on 16 December 2020, and Raghe Abdi (22), a radicalised young man on bail being monitored by cou…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
27y · Male·acute myeloid leukaemia
Hayden Dawes, aged 27, died from acute myeloid leukaemia (AML) while in custody at Mannus Correctional Centre on 30 December 2018. He had previously been treated for Hodgkins Lymphoma with BEACOPP chemotherapy (2014-2016…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
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