1,172 results
39y · Female·Gunshot wound to the head
A 39-year-old woman with brief psychotic disorder experiencing suicidal and homicidal ideation killed her 4-year-old daughter and herself. She had been diagnosed with psychosis in 2015, treated with olanzapine, and disch…
38y · Male·Aspiration pneumonia
Scott Hambly, a 38-year-old life prisoner with dilated cardiomyopathy, epilepsy, and schizophrenia, died from aspiration pneumonia at Wolston Correctional Centre in December 2018. He was identified as needing cardiology …
37y · Female·Multiple drug toxicity
Sharni Dee Connolly, a 37-year-old registered nurse turned naturopath, died from multiple drug toxicity following a hamstring injury requiring opioid analgesia. She was prescribed excessive quantities of pregabalin (105m…
27y · Male·Gabriella: Multiple stab wounds; Tafari: Gunshot injuries to the head and abdome…
Two deaths in a domestic violence and police operation context. Gabriella Thompson, 27, was fatally stabbed by her partner Tafari Walton in domestic violence circumstances on 13 March 2019. Police received a concern for …
9y · Male·Traumatic head injury with diffuse cerebral swelling and subdural haemorrhage ca…
Bradyn Dillon, aged 9, was brutally beaten to death by his father Graham Dillon in February 2016. The inquest examined how multiple agencies—police, child protection, education, and health services—failed to protect him …
64y · Male·Hypostatic bronchopneumonia complicating end stage Parkinson's disease
Gary Edward Holmes, 64, died from hypostatic bronchopneumonia complicating end-stage Parkinson's disease while receiving palliative care at Colac Hospital. He was a profoundly disabled man (deaf and blind from childhood)…
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…
44y · Male·Gunshot wound to the head
Jason Smith, 44, was shot in the head by his uncle John Pozzebon in a family violence incident. The coroner found that while Pozzebon had a valid firearms license, his mental health had deteriorated significantly followi…
47y · Male·sequelae of ruptured brain aneurysm
John Laurenson, a 47-year-old remand prisoner, died from rupture of a brain aneurysm on 20 June 2017, four days after collapsing in his prison cell. He had multiple intracranial aneurysms identified in 2015-2016, includi…
35y · Female·multiple injuries sustained in fall from sixth-floor balcony
FJ, an Iranian woman with bipolar affective disorder and schizophrenia, died by suicide at age 35 in November 2016. Key clinical lessons include: (1) the critical importance of continuity of psychiatric care during trans…
61y · Male·Hanging
Stanley Bruce Weaver, a 61-year-old firefighter with a history of depression and previous suicide attempts, died by hanging at his workplace on 26 August 2019. His wife had reported concerns about medication stockpiling …
36y · Male·bronchial asthma
Nathan Reynolds, a 36-year-old Aboriginal man with severe asthma, died from bronchial asthma in prison on 1 September 2018. His death exposed critical failings in both immediate emergency response and chronic disease man…
24y · Male·Gunshot wound to the head
A 24-year-old man with bipolar disorder and ADHD died by gunshot wound to the head approximately 5 months after a serious suicide attempt by overdose. He had been assessed as fit to hold a firearms licence by his treatin…
39y · Male·Choking on a food bolus
Mark Capovilla, a 39-year-old man with severe intellectual disability, epilepsy, and dysphagia, died from choking on food at his day program. He had a documented choking risk but lacked a current mealtime support plan at…
29y · Male·Combined drug toxicity (pregabalin, dihydrocodeine, tramadol, temazepam, lorazep…
A 29-year-old man with class III obesity died from combined drug toxicity involving pregabalin, dihydrocodeine, tramadol, temazepam, and lorazepam. He engaged in prescription medication abuse over 12 months, consulting a…
22y · Male·Hypoxic ischaemic encephalopathy complicating hanging
Christopher Ritson, a 22-year-old with severe alcohol and polysubstance dependence (ICE, cannabis), depression, anxiety and social phobia, died by suicide via hanging on 17 March 2020, four days after discharge from hosp…
34y · Female·Head injuries from blunt force trauma (multiple blows from axe); abdominal injur…
A 34-year-old pregnant woman died from severe head and abdominal injuries inflicted by her estranged partner in a domestic violence homicide. The death followed escalating domestic and family violence (DFV) including phy…
20y · Male·Hanging
Mitchell Dowling, a 20-year-old university student, died by hanging on 18 July 2018 after a period of psychological treatment for depression with suicidal ideation. He had presented with major depressive disorder with at…
70y · Male·carcinoma of the lung
Stuart Dugan, a 70-year-old prisoner with advanced lung cancer, died in hospice care. He had multiple missed opportunities for earlier diagnosis. While smoking-related lung cancer commonly presents late with poor prognos…
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