49 results
57y · Female·Head and chest injuries due to motor vehicle collision (driver)
A 57-year-old woman with insulin-dependent diabetes died in a motor vehicle collision caused by hypoglycaemia while driving. Her insulin pump data showed 16 hypoglycaemic events in the preceding month, with multiple epis…
70y · Male·Hanging
A 60-year-old man with recent pituitary surgery developed persistent fatigue and depressive symptoms. Despite normal cortisol levels, he remained convinced his symptoms were due to hormonal deficiency rather than depress…
38y · Male·Sepsis complicating bronchopneumonia and chest wall abscess in the setting of an…
A 38-year-old man with secondary adrenal insufficiency from childhood chemoradiation died from sepsis complicating a chest wall abscess and bronchopneumonia, precipitated by an adrenal crisis. He presented to his GP with…
Female·Hanging
This finding concerns the deaths of TC, a young mother, and SN, her 17-month-old daughter, who died by hanging on 21 September 2015 in Campsie, NSW. SN had significant life-limiting medical conditions including bilateral…
29y · Male·cardiac arrhythmia
David Dungay, a 29-year-old Aboriginal man with chronic schizophrenia, type 1 diabetes, and obesity, died on 29 December 2015 in Long Bay Hospital's Mental Health Unit while in custody. The immediate trigger was his refu…
17y · Male·Diabetic ketoacidosis
Caleb Pearson, a 17-year-old with undiagnosed Type 1 diabetes, presented with pharyngitis and was diagnosed and treated for a throat infection by his GP on 25 May 2015. Over the following two days he deteriorated with vo…
7y · Male·cardiorespiratory failure in a child with cerebral palsy and epilepsy, with acut…
Child KT (Vinnie), age 7, died of cardiorespiratory failure from cerebral palsy and epilepsy after a prolonged hospital admission. He had complex medical needs including chronic respiratory disease, requiring PEG feeding…
33y · Female·Hypoxic ischaemic encephalopathy with an antecedent cause of in-hospital cardiop…
Melissa King, aged 33, died from hypoxic ischaemic encephalopathy following in-hospital cardiopulmonary arrest at Blacktown Hospital. She presented with severe malnutrition, electrolyte derangements including hyponatraem…
31y · Female·incised wounds to the neck and arms
A 31-year-old illustrator with a recent onset of acute depression and suicidal ideation attended Fremantle Hospital ED via ambulance after GP referral on 12 May 2014. She had made a suicide attempt at a beach two days ea…
55y · Male·Aspiration pneumonia arising as a consequence of severe acquired brain injury
Sydney Dale Stanfield, 55, died from aspiration pneumonia secondary to severe acquired brain injury sustained in childhood. He resided in a disability accommodation service group home and had multiple comorbidities inclu…
49y · Female·Widespread small and large bowel, splenic and hepatic infarction secondary to se…
Susan Bourke, a 49-year-old woman, died from widespread small and large bowel infarction secondary to severe aortic atherosclerosis causing critical stenosis of the superior mesenteric and coeliac arteries. She presented…
66y · Male·unascertained
A 66-year-old man with insulin-dependent diabetes mellitus and severe hypoglycaemia unawareness died on 20 June 2013, the day after commencing a Medtronic Paradigm insulin pump. He was found collapsed at home after plann…
33y · Male·presumed fatal cardiac arrhythmia in the presence of coronary artery atheroscler…
Dr Peter Domachuk, a 33-year-old physicist, was admitted to Hornsby Hospital on 27 December 2012 with abdominal pain, nausea, vomiting and joint pain. His presentation included hypotension (97/61), tachycardia (116/min),…
86y · Male·Septic shock secondary to urosepsis
Robert Avery, 86, was admitted to Valley Private Hospital for colonoscopy to investigate constipation. After the procedure was cancelled due to respiratory concerns, he was managed with fluid restriction, bowel preparati…
5y · Male·unascertained
A 5-year-old boy and his sister (3 years old) and mother were killed by their father between 28-29 April 2012 in their Glen Waverley home. The father, who had experienced cognitive impairment and mood changes following a…
35y · Female·homicide by smothering/suffocation, possibly facilitated by chloroform exposure
This tragedy involved the deaths of Preetika Sharma (35), her two children (Divesh, 5; Divya, 3), and her husband Nilesh, who killed his family and then himself. Mr Sharma exposed family members to chloroform before smot…
36y · Male·Hanging (Mr Sharma); Homicide by smothering/suffocation or chloroform exposure (…
Nilesh Sharma, a 36-year-old Fiji Indian man, killed his wife Preetika, son Divesh (5 years old), and daughter Divya (3 years old) between 28-29 April 2012, then died by hanging. Evidence suggests he exposed them to chlo…
10y · Male·Hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
A 10-year-old boy with severe obstructive sleep apnoea and morbid obesity died from hypoxic brain injury following cardiorespiratory arrest. Despite repeated medical interventions and explicit warnings that his condition…
10y · Male·hypoxic ischaemic encephalopathy following cardiorespiratory arrest due to compl…
AA, a 10-year-old boy with morbid obesity and severe obstructive sleep apnoea, died from hypoxic brain injury after a cardiorespiratory arrest. He had been admitted to hospital in May 2008 with these diagnoses and was pr…
42y · Male·Cardiac arrhythmia secondary to electrolyte imbalance (hyperkalaemia) and verapa…
Glen Kingsun, 42, died from cardiac arrhythmia secondary to electrolyte imbalance and verapamil toxicity. He had complex medical needs requiring multiple specialist and GP care. Critical failures occurred: (1) Medication…
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