1,172 results
58y · Male·Heroin toxicity
58-year-old man with chronic back pain, paranoid schizophrenia, and decades-long prescription opioid and benzodiazepine abuse died from heroin toxicity. He had been successfully withdrawn from opioids (MS Contin, Endone)…
44y · Male·Hanging
A 44-year-old man died by hanging in a prison cell two days after reception. Despite disclosing a history of depression and recent heavy methamphetamine use, he was not prescribed his usual escitalopram medication, was p…
13y · Male·Epileptic seizure with aspiration
Child L, a 13-year-old boy with autism, cognitive impairment and poorly controlled generalised epilepsy, died from sudden unexpected death in epilepsy (SUDEP) with aspiration. His seizures remained refractory despite app…
17y · Female·Arrhythmia due to myocardial scarring secondary to past myocarditis, possibly fr…
Holly Brown, 17, died of fatal cardiac arrhythmia from undiagnosed heart scarring likely due to childhood rheumatic fever. She collapsed at a regional mass gathering event (2000+ attendees) in remote Laura, Queensland. C…
38y · Male·Toxicity to heroin
A 38-year-old man with a 24-year history of heroin addiction died from heroin toxicity shortly after release from prison. He had recently completed a 3-month custodial sentence and was released on 22 June 2018, dying on …
60y · Female·Pulmonary thromboembolism in a woman recovering from a fractured right ankle
Maria Kerr, a 60-year-old woman with obesity and thalassemia minor, died from pulmonary thromboembolism 33 days after sustaining a fractured ankle. An administrative error resulted in her urgent orthopaedic follow-up app…
48y · Female·Combined toxic effect of prescription and non-prescription medications including…
Lauren Johnstone, aged 48, died from the combined toxic effects of prescription and non-prescription sedative medications including oxycodone, tramadol, codeine, zopiclone, doxylamine and fluoxetine. She had undergone mu…
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…
24y · Male·bronchopneumonia complicating oxycodone toxicity
Matthew Neil Hardy Tonkin was a 24-year-old Australian Army veteran with post-traumatic stress disorder and chronic pain who died from bronchopneumonia complicating oxycodone toxicity. He engaged in prescription shopping…
54y · Male·incised wound to the neck
Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incar…
32y · Male·self-inflicted hanging
Sean Collins, a 32-year-old American chef on a work visa who became imprisoned in the Northern Territory, died by suicide in prison custody. He had multiple unaddressed risk factors: first incarceration, lengthy sentence…
34y · Male·ligature compression of the neck
Fazel Chegeni Nejad, a 34-year-old Iranian asylum seeker, died from ligature compression of the neck in the jungle near Christmas Island immigration detention centre on 8 November 2015. He had spent 1,477 days in detenti…
63y · Male·Unknown
William Willms disappeared on 23 July 1973 at age 63 after boarding a bus to Lilydale railway station. He had recently self-discharged from psychiatric admission for endogenous depression and suicidal ideation. Despite e…
59y · Male·mixed drug toxicity (tramadol and sertraline), likely serotonin syndrome
A 59-year-old man died from mixed drug toxicity involving tramadol and sertraline, likely precipitating serotonin syndrome. He was prescribed tramadol 150mg morning and 100mg evening (total 250mg daily), but evidence ind…
50y · Male·Hypoxic-ischaemic encephalopathy secondary to choking on food bolus
A 50-year-old man with acquired brain injury and intellectual disability died from hypoxic-ischaemic encephalopathy following aspiration of a food bolus during lunch at his disability care residence. The carer appropriat…
77y · Male·Chest and pelvic injuries sustained in a farming incident
A 77-year-old farmer died from chest and pelvic injuries sustained in a farm machinery incident. Mr Hulland was operating a Ford utility with an attached hydraulic trailer in low gear without a driver, a common practice …
40y · Male·Toxic effects of a gas
Nathan Shanahan, a 40-year-old former ADF member, died from toxic gas inhalation in his vehicle. He had struggled with depression, anxiety, and PTSD following service in the Solomon Islands where he witnessed a sexual as…
multi-drug toxicity (opioids, heroin, benzodiazepines, prescription drugs)
This inquest examined six opioid-related deaths in NSW occurring in May 2016, with causes ranging from heroin and fentanyl toxicity to multi-drug overdoses. The coroner identified multiple preventable factors: inadequate…
40y · Female·Clozapine toxicity in a woman with cardiomegaly
A 40-year-old woman with depression, anxiety, alcoholism and undiagnosed cardiomegaly died from clozapine toxicity after obtaining the drug from a co-resident at a Peer Recovery Community. She was not prescribed clozapin…
88y · Female·Sepsis complicated by multiple organ failure in a woman with comorbidities in th…
An 88-year-old woman died from sepsis with multiple organ failure following shoulder surgery. She developed an undiagnosed urinary tract infection after placement of an indwelling catheter. Critical failures included: in…
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