1,175 results
26y · Male·self-inflicted gunshot wound to the head while suffering severe depression
Morgan Hill, a 26-year-old NSW police officer, died by self-inflicted gunshot wound in March 2009 while severely depressed. Over 20 months prior to death, he experienced escalating mental health difficulties with work ab…
50y · Female·compression of the neck consistent with hanging
Yan Yi Xu, a 50-year-old woman with a history of depression and recent breast cancer diagnosis, was admitted to Cramond Clinic psychiatric ward following a suicide attempt on Christmas Day 2008. She died by hanging in he…
8y · Male·Septic shock consequent on burst appendix with peritonitis
Jacob Belim, aged 8, presented to a GP with appendicitis on 24 March 2009 but the diagnosis was missed. The next day, his treating doctor correctly diagnosed ruptured appendix and referred him urgently to hospital. At Li…
41y · Male·Neck compression subsequent upon hanging
A 41-year-old man with depression, anxiety and prior suicidal ideation died by hanging on the morning of a scheduled psychology appointment. He had been referred by his GP for psychiatric care five days prior following a…
91y · Female·pulmonary thromboembolism and subcutaneous abscess formation complicating pressu…
A 91-year-old woman died from pulmonary thromboembolism and abscess formation complicating untreated ankle fracture and pressure sores. She had sustained a fracture-dislocation of her right ankle after a fall, which she …
41y · Female·Hanging
Patricia Webster, a 41-year-old with a history of major depressive disorder, was admitted to hospital on 8 October 2009 after stopping antidepressants. She was discharged on 21 October with community mental health follow…
64y · Female·Bilateral pulmonary embolism with left middle cerebral artery/posterior cerebral…
Marlene Kenny, 64, presented to Orbost Hospital on 8 January 2007 with chest tightness, breathing difficulties and low oxygen saturation (83-86%). A doctor diagnosed panic attack and discharged her without investigation.…
40y · Male·Hypoxic brain injury consequent upon cardiac disease, possible viral infection o…
Michael Peter Magro, a 40-year-old male inmate at a correctional facility, died on 27 December 2008 from hypoxic brain injury following cardiac disease and severe pneumonia. Critical failures in prison healthcare were id…
32y · Female·hypoxic brain injury as a result of a cardiac arrest due to positional asphyxia …
A 32-year-old woman with schizophrenia, well-controlled on clozapine, became pregnant. Poor communication between her general practitioners, community mental health service, and the hospital meant the hospital was unawar…
28y · Female·bronchopneumonia complicating oxycodone toxicity
Melissa Jay Tatchell, aged 28 with severe anorexia nervosa (BMI 11.8, weight 29kg), died from bronchopneumonia complicating oxycodone toxicity. A locum doctor with no prior experience with oxycodone prescribed inappropri…
65y · Female·Ischaemic heart disease (coronary artery atherosclerosis); probable cardiac arrh…
Dorothy Plumb, a 65-year-old woman with intellectual disability living in a residential unit, was found unresponsive in bed and pronounced dead. Autopsy revealed significant coronary artery atherosclerosis with triple ve…
59y · Female·Subdural haemorrhage from blunt force trauma to head sustained in a backwards fa…
Lena Divola, a 59-year-old woman with intellectual disability, schizophrenia, and depression living in supported accommodation, sustained a head injury on 24 December 2007 when she fell backwards from a walker being push…
68y · Female·Multi-organ failure associated with septic shock following duodenal perforation …
Athenia Hana Walden, 68, died from multi-organ failure and septic shock following duodenal perforation during laparoscopic surgery at Swan District Hospital on 8 May 2008. Surgery was performed to remove her gallbladder,…
30y · Female·Multi organ failure from hydrochloric acid ingestion
Ms P, a 30-year-old woman with recent-onset depression and anxiety, died from multi-organ failure following intentional hydrochloric acid ingestion on 22 September 2008. She had presented to mental health services on 18 …
37y · Male·Mixed drug toxicity (heroin, methadone and diazepam) in a man with coronary arte…
Michael Gledhill, 37, died from mixed drug toxicity involving heroin, methadone, and diazepam, complicated by pre-existing coronary artery disease. He was enrolled in a methadone maintenance program but continued illicit…
34y · Female·Multiple injuries from pedestrian motor vehicle collision; suicide by stepping i…
Jennifer Bell, a 34-year-old woman with severe postnatal depression, obsessive-compulsive disorder, and borderline personality disorder, died by suicide on 2 October 2007 after stepping into the path of a truck. She had …
64y · Male·Large pulmonary embolus (origin undetermined)
Paul Brauer, 64, died of pulmonary embolus at Leeton District Hospital following a complex admission involving psychiatric depression, atrial fibrillation, urinary retention, and multiple comorbidities. The coroner ident…
16y · Female·obstructed breathing and heart arrhythmia secondary to severe obstructive sleep …
A 16-year-old Aboriginal girl with severe obstructive sleep apnoea died unexpectedly in her home one week before scheduled surgery. She had been symptomatic since age 13, but surgery was delayed for four years due to mul…
29y · Female·Effects of multiple injuries sustained when she projected herself from the top o…
Charmaine Dragun, a 29-year-old newsreader, died by suicide at The Gap on 2 November 2007. She was diagnosed with depression and treated with escalating doses of antidepressants (Efexor, then Lexapro) by multiple health …
37y · Female·Hypoxic brain injury consequent upon hanging
Louise Litis, 37, died from hypoxic brain injury following a hanging at Northpark Private Hospital's Mother and Baby Unit on 7 December 2007. She had severe recurrent postpartum depression and had attempted suicide two w…
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