1,172 results
37y · Male·Combined effects of presumed heavy metal poisoning from an unknown material and …
A 37-year-old man with schizophrenia died between 14–18 August 2020 in bushland near Whiteman Creek NSW, from presumed heavy metal poisoning and freshwater drowning. He was experiencing a psychotic episode related to unm…
55y · Male·Complications of alcohol use disorder
Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequa…
29y · Male·Mixed drug toxicity (gabapentin, codeine, diazepam, oxycodone, doxylamine, prome…
A 29-year-old man died from mixed drug toxicity involving multiple CNS depressants. His GP, Dr X, had maintained an inappropriate three-year sexual relationship with the patient while prescribing escalating doses of opio…
32y · Female·Compression of the neck
FSZ, a 32-year-old woman, was killed by her intimate partner NLU through compression of the neck (strangulation) on 24 April 2019. This coronial finding identifies multiple systemic failures in family violence response a…
39y · Female·MJU: stab wounds to the neck and chest; KJH: stab wounds to the back
MJU (39) and her daughter KJH (6) were killed by MJU's husband CTH in a family violence homicide on 13-14 January 2022. CTH, who was using methylamphetamine and experiencing drug-induced psychosis with visual hallucinati…
2y · Male·Cardiorespiratory arrest in a young child with opioid (morphine) toxicity
David Flynn was a healthy 2-year-8-month-old boy who died after circumcision under sedation with morphine at a private general practice clinic on 7 December 2021. Critical failures included: no fasting instructions despi…
31y · Male·asphyxia due to self-inflicted hanging
Benjamin Marshall, aged 31, died by self-inflicted hanging in October 2019, over two years after discharge from the Royal Australian Navy. He suffered from Bipolar Affective Disorder (BPAD), a genetic condition not causa…
30y · Male·unknown - no postmortem examination performed
This inquest examined the 1995 disappearance of Habtom Ghilagaber, a 30-year-old Eritrean mathematics PhD student at UNSW who was reported missing on 25 September 1995, having last been seen alive on 5 September 1995. Th…
21y · Female·Compression of the neck secondary to hanging
Lillian Rose Thomas, 21, died by hanging on 17 November 2021 at her home in Kyabram, Victoria. She had complex mental health conditions including CPTSD, anxiety, depression, OCD, and personality disorder traits, with a h…
62y · Male·Multiple sharp force injuries intentionally inflicted by client during home visi…
Stephen James Douglas, a 62-year-old community mental health nurse, was killed on 28 November 2019 by his client Peter Kemball during a home visit. Kemball had chronic schizophrenia and was experiencing psychosis with de…
41y · Female·Aspiration pneumonia in the setting of a mixed drug toxicity
Emma Terrill, 41, died from aspiration pneumonia in the setting of mixed drug toxicity. Post-mortem toxicology revealed elevated tramadol with benzodiazepines (alprazolam, diazepam, temazepam, oxazepam) causing synergist…
57y · Female·starvation due to insufficient food intake
Patricia Iliev, a 57-year-old woman, died from starvation after progressively restricting her food intake over months while immobilised by chronic back pain. She had a gastrointestinal stromal tumour and advanced lung di…
33y · Male·Mixed drug toxicity
A 33-year-old man with complex psychiatric history (bipolar disorder, schizoaffective disorder, autism, ADHD) and long-standing substance use disorder died from mixed drug toxicity. Postmortem toxicology revealed high-co…
78y · Female·Complications of prolonged immobility and malnutrition in a woman with retroperi…
A 78-year-old woman with schizophrenia, depression, and undiagnosed retroperitoneal lymphoma died from septic shock complicating severe pressure ulcers, malnutrition, and dehydration. She had been immobile on a couch for…
50y · Male·plastic bag asphyxia in the setting of ethanol intoxication and blunt force head…
William Heddergott, 50, died from asphyxiation with head injuries while intoxicated, in circumstances suggesting his mother Erica (who pleaded guilty to murder) perpetrated fatal family violence. Clinical lessons include…
65y · Male·Pneumonia, due to chronic lung disease with atherosclerotic cardiovascular disea…
A 65-year-old man with severe chronic lung disease, COPD, and coronary artery disease died at home. Evidence suggests he deliberately ingested benzodiazepines and possibly other substances in a self-harm attempt. However…
30y · Female·Hypoxic ischaemic encephalopathy complicating cardiac arrest of unknown aetiolog…
Heather Calgaret, a 30-year-old Aboriginal woman, died from hypoxic ischaemic encephalopathy after being administered a first dose of buprenorphine (Buvidal) injection without prior stabilisation on sublingual Suboxone. …
60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contr…
James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duo…
62y · Male·Hypoxic ischaemic encephalopathy complicating cardiac arrest in setting of acute…
John Michael Jurdeczka, a 62-year-old man with autism, intellectual disability, and dysphagia, died from hypoxic ischaemic encephalopathy following cardiac arrest caused by acute upper airway obstruction from a food bolu…
31y · Male·Drowning
Nathan Markl, a 31-year-old man with a history of mental illness, intellectual impairment, and substance use disorder, died by drowning in Narrabri Creek on 7 July 2021. He was intoxicated and under the influence of meth…
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