4,457 results
59y · Male·Choking asphyxia
Tom Owen Row, a 59-year-old man with intellectual disability, dementia, Fragile X Syndrome, and Chromosome 18 Deletion Syndrome, died from choking asphyxia at a residential care facility. He had a prior choking incident …
72y · Female·subdural haemorrhage sustained from a fall from a hospital bed on 18 January 201…
Mrs Judith Gaye Flynn, aged 72, died from a subdural haemorrhage sustained when she fell from a hospital bed on the General Medicine Ward at Canberra Hospital. She was a high-risk fall patient with cognitive impairment, …
2y · Unknown·Drowning
Child C, a 2-year-old living on a rural property in Victoria, drowned in an unsupervised dam. Child Protection had received six reports over 2.5 years documenting neglect, poor supervision, and cumulative harm, but close…
36y · Male·Cannot be determined
CD, aged 36, disappeared on 17 June 2019 after exhibiting significant mental health deterioration, recent suicidal ideation, paranoia, alcohol abuse, and relationship breakdown. The coroner found sufficient evidence that…
81y · Male·cardiac arrest following neck compression due to hanging
An 81-year-old man with a history of alcohol dependence, paranoid delusions regarding his wife's infidelity, and possible vascular dementia was admitted to mental health facilities involuntarily after discharging a firea…
71y · Male·Complications of metastatic squamous cell carcinoma (terminal palliation)
Leslie Shortte, a 71-year-old life prisoner, died from metastatic squamous cell carcinoma with complications. Critical failures in his prison medical care included: failure to complete annual health assessments after 201…
47y · Male·Multiple gunshot wounds; discharged by police officer during enforcement of Comm…
Ian Fackender, aged 47, died from gunshot wounds during a Community Treatment Order breach enforcement operation in his home. He had severe, treatment-resistant schizophrenia and was acutely psychotic during the incident…
42y · Male·Complications post polypharmacy toxicity
Gregory Sedgman, aged 42, died from polypharmacy toxicity after consuming excessive prescription medications at a post-sentence supervision residential facility. He had deliberately accumulated medications despite a seiz…
41y · Female·neck compression
Kim Lynch, 41, died from neck compression between 12-14 February 2016. She was in a relationship with LM, who had paranoid schizophrenia, substance abuse issues, and a history of violence. Following a family violence inc…
17y · Male·Hypoxic ischaemic encephalopathy due to hanging
A 17-year-old male who transitioned from female died by hanging on 21 April 2020, seven days after discharge from psychiatric inpatient care. He had complex medical needs including chronic back pain, spinal fusion, post-…
30y · Male·Sudden unexpected death in epilepsy
Vanelee Mitchell, a 30-year-old First Nations man with epilepsy, died suddenly in custody at Townsville Correctional Centre on 10 April 2020. He had suffered a head injury in 2014 resulting in acquired brain injury and s…
21y · Male·Hypoxic brain injury in the setting of drug toxicity
21-year-old Bazouni Bazouni died from hypoxic brain injury following methamphetamine toxicity ingested at Port Philip Prison. While the coroner concluded the death was not preventable given the excessive drug ingestion, …
55y · Male·Acute alcohol toxicity
Alan Wilson, a 55-year-old man with intellectual disability, schizophrenia, and severe alcohol addiction, died from acute alcohol toxicity in an aged care facility. Post-mortem blood alcohol concentration was 0.33%, suff…
40y · Female·Complications of WHO Class III Obesity
Cindy Jane Martin, a 40-year-old Aboriginal woman with treatment-resistant schizophrenia, WHO Class III obesity, and obstructive sleep apnoea, died of sudden cardiac complications seven days after psychiatric admission. …
28y · Male·neck compression consequent upon hanging
A 28-year-old man with severe personality disorder, substance use history, and recent suicidal ideation died by hanging. He was admitted to mental health services on 25 February 2019 after suicide threats and high-lethal…
65y · Male·Unascertained - likely drowning after falling overboard
A 65-year-old experienced sailor died after falling overboard from his yacht in the Bass Strait while solo sailing. He was likely suffering hypoxia caused by a slow LPG gas leak into the cabin, combined with sleep depriv…
33y · Female·Hypoxic ischaemic encephalopathy complicating mixed drug toxicity
Jessica Higgins, a 33-year-old woman with chronic pain and opioid dependence, died from hypoxic ischaemic encephalopathy following mixed drug toxicity. She underwent a ketamine infusion with opioid rotation from oxycodon…
31y · Male·Complications of methylamphetamine use in a setting of physical restraint in a m…
Anthony Georgiou died on 12 September 2016 after a physical struggle with security officers at Bunnings. He had taken unpaid merchandise and was confronted by loss prevention officers (LPOs) Brenzai and Oyee. When Georgi…
19y · Male·Hanging
LAK, a 19-year-old Aboriginal man, died by suicide at a community rehabilitation facility after a complex mental health journey involving forensic orders and psychosis. Key clinical lessons include: recognising vulnerabi…
62y · Female·Hypovolaemic and cardiogenic shock (hysterectomy) in the context of cardiomegaly…
A 62-year-old woman with significant comorbidities (cirrhosis, cardiomegaly, thrombocytopenia, chronic kidney disease, COPD) died from hypovolaemic and cardiogenic shock during elective total laparoscopic hysterectomy fo…
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