1,175 results
49y · Male·Hanging
A 49-year-old man with bipolar affective disorder and recurrent depression experienced a relapse while in Tasmania and was referred to a community-based Acute Care Team in Queensland in November 2009. Despite his partner…
Toxicity from intravenous caesium, DMSO, and other substances administered as pa…
In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr B.'s home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and La…
27y · Male·Gunshot wound to the chest fired by Sergeant Matthew Gale of the Australian Fede…
Nathan Doherty, aged 27, died from a gunshot wound inflicted by AFP Sergeant Matthew Gale during a mental health crisis. Nathan had a long history of depression, anxiety, and alcohol abuse, with two prior suicide attempt…
Salmonella infection contributing to deaths in gastroenteritis outbreak
Four elderly residents of Broughton Hall aged care facility died during a 2007 Salmonella gastroenteritis outbreak. A three-day delay in notifying the Department of Health (April 7 to April 10) prevented early identifica…
19y · Female·asphyxiation
A 19-year-old university student with chronic bilateral uveitis presented to university counselling with depression. She disclosed detailed written suicide plans (helium asphyxiation) to the Head of Counselling, who appr…
16y · Male·Pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcu…
Andrew Allan, a 16-year-old student, died from pneumonia complicating influenza A (H1N1) infection with secondary Staphylococcus aureus septicaemia. He presented to Northam Regional Hospital Emergency Department on 16 Se…
38y · Male·Toxic effects of morphine in a setting of benzodiazepine dependency
A 38-year-old man with chronic pain, mental illness, and benzodiazepine dependency died from morphine toxicity. He obtained multiple benzodiazepines and opioids from five different doctors through 'prescription shopping'…
55y · Male·Hanging
Peter Tully, 55, died by hanging 4 days after discharge from his first psychiatric admission for major depressive disorder with suicidality. He had made 3 suicide attempts in the week before admission. During hospitalisa…
29y · Female·Hypoxic Encephalopathy consequent upon Cardiorespiratory Arrest arising from eit…
Helen Grainger, 29, with polycystic kidney disease and asthma, underwent pregnancy termination at Lambton Road Day Surgery in April 2007. She developed anaphylaxis post-procedure (likely cephalosporin-triggered) with car…
Unknown·Multiple: Olanzapine toxicity, pulmonary thromboembolism, asphyxiation on food, …
This inquest examined six sudden deaths of residents at 300 Hostel, Marrickville, between June 2009 and August 2010. All residents had schizophrenia on multiple antipsychotic medications and severe, untreated physical co…
24y · Male·neck compression due to hanging
A 24-year-old man with depression and anxiety died by hanging in March 2009, three weeks after hospital discharge following an overdose. Critical clinical lessons emerge: (1) discharge summaries from psychiatric admissio…
37y · Male·combined ethanol and drug toxicity
Kenneth Agnew, a 37-year-old man resident in aged care, died from combined ethanol and drug toxicity involving methadone and benzodiazepines. He had hepatitis C and fatty liver disease. Critical clinical lessons include:…
43y · Female·Acute thrombosis of a prosthetic mitral valve
A 43-year-old woman with prosthetic mitral and aortic valves due to rheumatic heart disease died from acute thrombosis of her prosthetic mitral valve following cessation and recommencement of warfarin for IVF treatment. …
0y · Female·perinatal pneumonia in association with meconium aspiration
Baby Sharinka Patricia Little, born prematurely at 35 weeks at Dalwallinu Hospital on 20 March 2008, died from perinatal pneumonia with meconium aspiration the same day. Critical clinical failures occurred during her nin…
0y · Female·Unascertainable
Shar Rose Benfield, a 7-month-old Aboriginal infant born prematurely to parents with significant psychosocial challenges, died unexpectedly on 24 June 2008 at Kalgoorlie Hospital with an unascertainable cause. The child …
25y · Male·Ligature compression of the neck (hanging)
David Peter Ellery, a 25-year-old man with long-standing amphetamine addiction and deteriorating mental health, died by hanging on 31 July 2007. He presented to Bentley Hospital on 31 July with active suicidal ideation, …
34y · Male·head and neck trauma (train impact)
Simon MacQueen, a 34-year-old man with chronic schizophrenia and recurrent suicidality, died by stepping in front of a train on 15 December 2008. He had been discharged from inpatient psychiatric care on 12 November 2008…
55y · Male·Acute myocardial infarction due to coronary thrombosis and coronary atherosclero…
Leonard Fraser, a 55-year-old prisoner, died from acute myocardial infarction on 1 January 2007 following a second cardiac event. He presented to prison medical centre on 7 December 2006 with chest pain, sweating, and le…
37y · Male·mixed drug toxicity
A 37-year-old man with chronic pain from scoliosis and recurrent pancreatitis died from mixed drug toxicity. Over four months, he obtained prescriptions from 19 different doctors for multiple medications including opioid…
34y · Male·asphyxiation by hanging
A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not …
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