4,457 results
95y · Male·Head injuries (subarachnoid haemorrhage, frontal bone fracture and contrecoup) s…
A 95-year-old man admitted to hospital for fluid overload and cellulitis related to heart failure fell in his hospital room on day 11 of admission whilst attempting to walk to the bathroom without his walker or assistanc…
39y · Male·Lost at sea presumed drowned
Giovanni Castillo Garbanzos, a 39-year-old Filipino worker, was washed overboard from the commercial fishing vessel Lady Miriam in Bass Strait on 2 September 2021 during rough weather (20-30 knot winds, 2-3 metre swells,…
32y · Male·methylamphetamine toxicity
Joshua Steven Kerr, a 32-year-old Aboriginal man with intellectual disability and substance use disorder, died from methylamphetamine toxicity on 10 August 2022 at Port Phillip Prison. After lighting a fire in his cell a…
0y · Male·unascertained, in an unsafe sleeping environment, on a background of respiratory…
Baby Caleb, aged 2 months, died on 30 November 2018 in an unsafe sleeping environment while his mother co-slept with him on a fold-out sofa in a squalid home. He had a concurrent respiratory tract infection. The coroner …
13y · Female·Self-inflicted single gunshot wound to the chest
Grace, 13, died from a self-inflicted gunshot wound using an unsecured .308 Winchester rifle stored in her parents' bedroom. She had disclosed suicidal thoughts to a school counsellor in September 2021, but this disclosu…
44y · Female·Neck compression in the circumstances of hanging
A 44-year-old woman died by hanging following rape in 2014 and protracted criminal proceedings. She experienced ongoing trauma and PTSD exacerbated by reopening her complaint and multiple court processes. She had multipl…
41y · Male·complications in association with effects of fire, with terminal palliative care
Peter James Wilson, 41-year-old male with complex mental health history including bipolar affective disorder, anxiety, OCD, and possible schizophrenia, died by suicide on 1 November 2021 after self-immolating with boat f…
81y · Male·Chronic lung disease (severe COPD) with atherosclerotic cardiovascular and valvu…
An 81-year-old man with severe COPD died following inappropriate interhospital transfer to a private hospital and subsequent management errors. Key clinical lessons: (1) patients with CO2 retention require explicit ident…
44y · Male·Cardiac arrhythmia on a background of hypertensive heart disorder, obesity, diab…
Michael Baker, a 44-year-old Aboriginal man in custody at Lithgow Correctional Centre, died from cardiac arrhythmia on 25 June 2019. He had multiple comorbidities (hypertensive heart disease, obesity, type 2 diabetes, un…
84y · Male·head and pelvic injuries with contributing ischaemic and valvular heart disease …
An 84-year-old man under guardianship with dementia, cardiac disease, and on anticoagulation suffered an unwitnessed fall at an aged care facility and sustained head and pelvic injuries. Following the fall, a registered …
92y · Male·unascertained
A 92-year-old man with advanced dementia died in aged care following an unwitnessed fall on 3 December 2021. He deteriorated rapidly after a second fall at 11:45pm and died shortly after. The precise cause of death remai…
17y · Female·Neck compression by hanging (suicide)
XY, a 17-year-old Wemba Wemba Aboriginal girl, died by suicide on 18 July 2021 while in out-of-home care. The inquest found the Victorian Department of Families, Fairness and Housing (DFFH) failed in its duty of care as …
Female·Vlasta Wylucki: ischaemic heart disease due to coronary atherosclerosis (previou…
Two women died of natural causes in Queensland police watchhouses but supervisory failures raised serious concerns. Ms Wylucki (50) died from ischaemic heart disease after inadequate cell checks failed to detect her vomi…
49y · Male·Acute myocardial infarction complicating prosthetic valve thrombosis in a man wi…
Joshua Paul Coates, aged 49, died from acute myocardial infarction complicating prosthetic valve thrombosis following mechanical aortic valve replacement. Post-mortem examination revealed a large blood clot obstructing h…
90y · Female·fatal injuries from sustained attack by three dogs
Ada Holland, aged 90, was fatally attacked by three dogs on Collingwood Beach on 29 March 2020. One week prior, the same dogs escaped their owner's premises and attacked another person. Council rangers attended but faile…
Male·Drowning (Dr Xu); Undetermined - accidental drowning while intoxicated (Mr Davie…
Two men died after excessive alcohol consumption in Hobart waterfront venues. Dr B. (32), a trainee surgeon, consumed 9-10 whiskies and beers over several hours at three venues on 6-7 November 2019, reaching a blood alco…
46y · Male·head injury complicated by bronchopneumonia, with palliation
A 46-year-old remand prisoner died from traumatic brain injury sustained during a severe prison assault. Critical failures in responding to cell call alarms preceded the attack. Prison officers answered multiple distress…
37y · Male·Complications due to atherosclerotic heart disease and dyslipidaemia
Glen Dooley, a 37-year-old Aboriginal man, died of atherosclerotic heart disease and dyslipidaemia while in custody at Darwin Correctional Centre. His death was avoidable. He had abnormal ECGs in 2019 and 2022 that were …
48y · Male·Undetermined; most likely drowning at sea
Mahsan Muhammad, a 48-year-old Indonesian deckhand, fell overboard from a commercial fishing trawler (K-VERN) in rough seas off Queensland on 18 May 2020. He was working on a boom arm 10 metres outboard, attempting to re…
16y · Male·Injuries sustained in motor vehicle incident as a motorcyclist
Sebastian D'Imperio, 16, died from head injuries sustained while motocross riding at Frankston City Motorcycle Park when he failed to land safely after the last table-top jump, lost control, and was struck by another air…
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