4,457 results
17y · Male·hydrocarbon toxicity (petrol inhalation)
George Campbell, an Aboriginal youth with complex trauma, ADHD, and emerging volatile substance misuse, died aged 17 from hydrocarbon toxicity after inhaling petrol. While living with supportive kinship carers (Paul and …
30y · Male·ligature compression of the neck (hanging)
Jomen Blanket, a 30-year-old Aboriginal and Torres Strait Islander man, died by suicide in prison on 12 June 2019 after eight months incarcerated for assault. He had a known suicide plan (hanging from his cell door using…
75y · Female·Septicaemia (Staphylococcus aureus) with antecedent cause of septic arthritis
A 75-year-old woman with chronic pain and previous staphylococcal infections presented to Glen Innes District Hospital with a swollen, warm right knee 10 days after a corticosteroid injection. Junior doctor Dr M. appropr…
64y · Male·coronary atherosclerosis with early myocardial infarction
A 64-year-old man suffered acute myocardial infarction at home. His wife called triple-0 at 10:34 am reporting classic cardiac symptoms: sudden sweating, shortness of breath, and shoulder pain. The emergency dispatch sys…
27y · Male·Injuries sustained in motor vehicle collision (driver)
Jackson Eales, 27, died in a motor vehicle collision at an intersection when truck driver Gerard Voss failed to stop at a stop sign in December 2016. The coroner found it highly probable Voss had undiagnosed severe obstr…
28y · Male·neck compression from hanging
SH, a 28-year-old man, died by hanging in Cessnock Correctional Centre after seven weeks in custody. He was assessed at intake as having no self-harm risk and cleared for normal cell placement. During custody, he became …
27y · Male·Neck compression due to self-inflicted hanging
Matthew Grieve, a 27-year-old first-time inmate with anxiety, depression and panic disorder, died by self-inflicted hanging in custody after eight days without prescribed medication. Critical failures included: an unsign…
5y · Female·Hypoxic-ischaemic Encephalopathy due to methadone toxicity
LA, a five-year-old girl, died from hypoxic-ischaemic encephalopathy due to methadone toxicity on 22 January 2017. She ingested methadone at her grandfather's home while staying overnight; the grandfather was enrolled in…
51y · Male·asphyxiation due to diffusion of exhaust fumes into a car
A 51-year-old man died by suicide following workplace termination. After being stood down for attending work alcohol-affected on 17 July 2020, Mr Abeysinghe expressed suicidal intent to colleagues on multiple occasions. …
33y · Male·Haemoperitoneum secondary to lacerated spleen as a result of peritoneal ascitic …
A 33-year-old man with severe alcoholic liver disease (Child-Pugh C) and poor prognosis died from haemoperitoneum following splenic laceration during a diagnostic ascitic tap procedure. Two junior doctors (HMOs/Basic Phy…
45y · Female·mixed drug toxicity including heroin and methylamphetamine
Barbara Dobson, a 45-year-old woman with a long history of substance abuse, violent relationships, and mental health issues, died of mixed drug toxicity including heroin and methylamphetamine on 24 February 2020. Police …
32y · Male·Cerebral oedema secondary to dialysis disequilibrium syndrome
Andrew Stubbs, 32, died from cerebral oedema secondary to dialysis disequilibrium syndrome while receiving intermittent haemodialysis for severe lithium toxicity and acute kidney injury. Key preventable failures included…
84y · Female·pneumonia and fracture of the neck of right femur following a fall
Mrs Bell, aged 84, died from pneumonia and a fractured right femoral neck sustained in a fall at a residential aged care facility. She had advanced Alzheimer's disease, cognitive impairment, impulsive behaviour, and was …
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
92y · Male·left haemothorax and rib fractures resulting from a fall at a residential aged c…
A 92-year-old man with multiple comorbidities (cardiac failure, COPD, chronic renal failure, diabetes) and documented high falls risk sustained a fall at a residential aged care facility on 12 May 2021, resulting in left…
37y · Male·Gunshot wound to the head, with alcohol intoxication a significant contributing …
John Fredrick Schulte died by a self-inflicted gunshot wound on Christmas Day 2018 following the breakdown of his marriage. The inquest identified critical failures in police response to multiple domestic violence compla…
43y · Female·Complications of obesity including cardiomegaly
Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disability services group ho…
93y · Male·Alzheimer's dementia (as recorded on MCCD); however, the death resulted from a f…
Ronald Reginald Slatter, aged 93, died at Mersey Community Hospital on 22 July 2022, three weeks after sustaining a fractured neck of right femur from a fall on 1 July 2022. While the coroner found no issues with his cli…
81y · Male·Head injury sustained in a fall
Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…
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