1,172 results
1y · Male·Hypoxic-ischaemic encephalopathy and multisystem failure in the setting of extre…
Baby B was born by emergency breech extraction in an ambulance after obstructed labour, sustaining severe hypoxic-ischaemic injury. The death was multifactorial. The mother had limited antenatal care despite known metham…
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…
71y · Female·Ruptured abdominal aortic aneurysm, with coronary artery atherosclerosis contrib…
Sandra Cree, a 71-year-old woman, died from a ruptured abdominal aortic aneurysm (AAA) after undergoing an elective endovascular repair procedure in Brisbane. She presented to a remote hospital (Lightning Ridge Multi-Pur…
25y · Male·unable to determine
Tyrone Frederick MacQueen disappeared on 1 July 1994 at age 25. He had chronic schizophrenia with poor medication compliance, recent psychiatric hospitalization, expressed suicidal ideation, self-harm (wrist cutting), de…
72y · Female·Obstruction of the airways of the neck
A 72-year-old woman with moderate-severe expressive and receptive dysphasia following an acute left middle cerebral artery stroke died by hanging three months post-discharge from rehabilitation. Critical deficiencies wer…
44y · Male·mixed drug toxicity
Michael Allan Steer, aged 44, died from mixed drug toxicity after ingesting excess prescription medication (quetiapine, codeine, diazepam, fluoxetine). He had complex psychiatric history with factitious and somatic disor…
56y · Male·unascertained; presumed suicide by unknown means
Gerald Vanderwerf, a 56-year-old man with a 40-year history of severe depression, suicidal ideation, and multiple suicide attempts, disappeared from the Grampian Ranges on 23 September 2016. The coroner found on the bala…
54y · Male·Pneumonia due to Staphylococcus aureus
A 54-year-old man died in custody from Staphylococcus aureus pneumonia. Over 11 days before death, he presented multiple times with respiratory symptoms and requested antibiotics, but was never seen by a doctor. Key clin…
86y · Male·multi-organ failure due to sepsis on a background of sacral pressure ulcer
An 86-year-old man died from multi-organ failure due to sepsis from a stage 4 sacral pressure ulcer after 61 days in a regional hospital. Critical failures included delayed pressure injury risk assessment (7 days overdue…
66y · Male·carbon monoxide poisoning due to inhalation of exhaust gases from a lawn mower
Paul William Green, a 66-year-old retired engineer with longstanding depression, anxiety, PTSD, and chronic alcohol abuse, died by intentional carbon monoxide poisoning from a lawn mower exhaust. He had a prior suicide a…
64y · Male·Multiple injuries sustained after jumping from a height
MB, a 64-year-old man with progressive major depression, died from multiple injuries sustained after jumping from a cliff at the Skillion near Terrigal. Over 18 months, his mental health deteriorated with depressive symp…
24y · Male·Combined drug toxicity (heroin, benzodiazepine and others)
Samuel Morrison, 24, died from combined drug toxicity involving heroin, benzodiazepines and other substances. He had a long history of depression, anxiety and illicit drug use, and had recently been discharged from psych…
28y · Male·Mixed drug toxicity (synergistic effects of diazepam, oxycodone, and fentanyl ca…
Matthew McLachlan, a 28-year-old paraplegic with chronic pain from spinal cord injury, died from mixed drug toxicity while hospitalized for urinary tract infection treatment. He was receiving fentanyl patches, oxycodone,…
88y · Female·Multiple injuries (neck, chest, abdomen)
June Shirley Dangerfield, 88 years old, died from multiple injuries after a motor vehicle collision on 22 November 2016. She had been declared unfit to drive by her GP following pneumonia and sepsis in early 2016, but su…
34y · Female·Mixed drug toxicity
Diane Maria Hillgrove, a 34-year-old woman with chronic pain, PTSD, anxiety and substance abuse history, died from mixed drug toxicity on 7 July 2018. Post-mortem toxicology revealed elevated pregabalin (51 mg/L), morphi…
26y · Female·Multiple drug toxicity
Alissa Campbell, aged 26, died from accidental drug overdose caused by multiple prescription medications—predominantly codeine and doxepin in combination with benzodiazepines. She had accessed prescription drugs from at …
53y · Female·self-inflicted hanging
Paula Schubert, a 53-year-old with schizophreniform psychosis, died by hanging after experiencing workplace stress and abandonment by mental health services. Her employer initiated a demotion process despite her known me…
55y · Male·Combined effects of mixed drug (alcohol and promethazine) toxicity and environme…
A 55-year-old man with alcohol dependency died from combined alcohol and promethazine toxicity with heat exposure. He spent 4-5 hours sunbaking in high temperatures (exceeding 30°C) while heavily intoxicated and sedated …
24y · Female·hypoxic brain injury secondary to hanging
Chrystal Ross, a 24-year-old woman, died by hanging in hospital in January 2015 after a catastrophic chain of communication failures and care coordination errors. She had been admitted to Mount Barker Hospital for anxiet…
45y · Male·Combined effects of plastic bag asphyxia and helium gas inhalation
A 45-year-old man with a history of bipolar affective disorder and previous suicide attempts died by combined plastic bag asphyxia and helium gas inhalation. He hired a helium cylinder from a party supply store on 2 Octo…
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