232 results
72y · Male·Choking on a food bolus
A 72-year-old man with vascular dementia, stroke history, and dysphagia died from choking on food while being fed by a nurse in aged care. The coroner found the death was preventable due to staff lack of training in safe…
55y · Female·asphyxia due to choking on food (steak)
A 55-year-old woman with multiple comorbidities including morbid obesity, schizophrenia, depression, and substance use disorder died from asphyxia caused by choking on food while at a friend's home in supported accommoda…
26y · Male·ligature compression of the neck (hanging)
Callum Mitchell, aged 26, died by ligature compression of the neck (hanging) in his cell at Hakea Prison on 21 April 2019. He had a longstanding history of self-harm, severe personality disorders (borderline and antisoci…
41y · Male·heart failure related to exsanguination due to traumatic rupture of an arteriove…
Nicholas Summers, a 41-year-old kidney transplant recipient, died from traumatic rupture of an arteriovenous fistula with massive hemorrhage on 16 February 2016. He had returned to Tasmania under nephrologist Dr Mathew's…
58y · Male·chest and abdominal injuries sustained in motor vehicle collision
A 58-year-old experienced motorcycle rider died from massive chest and abdominal injuries after losing control on a rural curve and colliding with an oncoming vehicle. He was initially conscious with three doctors presen…
Mixed·Hannah Clarke: multi-organ failure due to effects of fire; Aaliyah, Laianah and …
Hannah Clarke, aged 33, and her three children (ages 6, 4, and 3) were killed by her estranged husband Rowan Baxter on 19 February 2020 in Camp Hill, Queensland. Baxter forced his way into Hannah's car, doused the family…
heat stroke (environmental exposure) / hyperthermia; Mr Buske: atherosclerotic h…
Four deaths occurred on Mount Augustus summit trail in 2019-2020 during hot weather conditions. All deceased experienced heat stroke with dehydration as the primary mechanism of death. The coroner identified inadequate p…
49y · Male·Complications of a right superficial femoral artery injury (operated) following …
A 49-year-old man died from complications of a right superficial femoral artery injury sustained when he was struck by a circular saw at a landscaping worksite. Despite receiving immediate first aid, emergency transport …
43y · Female·choking on a food bolus
Joanne Callahan, a 43-year-old woman with intellectual disability and autism, died from choking on a food bolus while attending a disability day program. Critical failures in communication between her residential care pr…
25y · Male·Hypoxic ischaemic brain injury due to hanging
Dylan Charlton-Smith, aged 25, died by hanging while in custody at Fulham Correctional Facility. A stressful visit from his partner preceded his death by approximately 50 minutes. A correctional officer identified distre…
30y · Male·Complications of methylamphetamine toxicity
Matthew Dongelmans, aged 30, died from complications of methylamphetamine toxicity after being arrested for breaching a family violence intervention order. He consumed methylamphetamine prior to arrest, likely in panic w…
17y · Unknown·hypoxic brain damage from out of hospital cardiac arrest
FL was a 17-year-old with complex medical needs including short bowel syndrome and dependence on total parenteral nutrition (TPN) via central vascular access device. In June 2020, he became severely unwell with deteriora…
36y · Male·hanging
A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, a…
39y · Male·Cardiac arrest in a person with pre-existing severe ischaemic heart disease who …
A 39-year-old First Nations man with severe ischaemic heart disease died following police restraint and ambulance care during an emergency examination authority detention. He had sniffed petrol and threatened self-harm; …
50y · Male·Tracheostomy site haemorrhage in a man with laryngeal squamous cell carcinoma (t…
A 50-year-old man died from tracheostomy site haemorrhage 36 days after laryngectomy for recurrent laryngeal cancer. He lived alone post-discharge with a MePACS personal alarm system and home nursing visits. When bleedin…
5y · Male·Sudden Unexpected Death in Infancy (SUDI +0); exact cause unascertained
A 5-month-old premature infant with low birth weight died suddenly and unexpectedly at home. Toxicological testing revealed the presence of frusemide (a diuretic medication) in his blood and other samples, which should n…
48y · Male·Ischaemic heart disease complicating restraint of an acutely agitated male
Daniel Richards, 48, died from ischaemic heart disease precipitated by restraint during a mental health assessment at home. He had underlying significant coronary artery disease with left ventricular hypertrophy and old …
3y · Female·complications of Influenza B viral infection
Three-year-old Caitlin Cruz presented to a medical centre unwell and collapsed, requiring resuscitation. She was transferred by ambulance to Children's Hospital at Westmead but critical information about her collapse and…
31y · Male·Hypoxic brain injury caused by the exogenous administration of insulin, resultin…
Jesse Drabsch, 31, died from hypoglycaemia after self-injecting insulin in a gym bathroom. A competitive bodybuilder using performance and image enhancing drugs (PIEDs), Jesse entered the bathroom at 5:30pm on 16 Novembe…
Unknown·Mr Christensen: stab wound to the chest. Mr Davy: blood loss caused by stab woun…
Two men died following stab wounds sustained while forcing entry to a dwelling in the early hours of 1 October 2018. The deceased had been misled about the circumstances of an injured woman they believed needed urgent as…
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