2,427 results
35y · Male·multiple organ failure due to out-of-hospital circulatory arrest due to perforat…
35-year-old male died from multiple organ failure following out-of-hospital cardiac arrest caused by perforated duodenum. He was in police custody for drug-related charges and diagnosed with opioid withdrawal. Critical d…
56y · Male·Multiple injuries sustained in a motor vehicle collision
Harri Jokinen, aged 56, died following a head-on motor vehicle collision on the Monaro Highway when a stolen Commodore being pursued by NSW police crossed into his lane. Clinical lessons: This was a non-medical death but…
0y · Male·subgaleal haematoma and subarachnoid haemorrhage complicating a prolonged labour
Baby W died within 40 minutes of birth from subgaleal haematoma and subarachnoid haemorrhage following a failed instrumental delivery for prolonged labour. The coroner identified critical missed opportunities in decision…
54y · Female·Pulmonary thromboembolism complicating left calf deep venous thrombosis in the s…
54-year-old woman with frontotemporal dementia and Parkinson's disease died from pulmonary thromboembolism complicating deep venous thrombosis. She fell during the night at a disability accommodation facility and was fou…
40y · Female·Stab wounds to the chest and abdomen
A 40-year-old woman was fatally stabbed by her former intimate partner who had an extensive history of family violence offending and multiple breaching intervention orders. Despite multiple service contacts in the days b…
57y · Female·Asphyxia - Inhalation of liquefied petroleum gas (LPG)
Mrs R, a 57-year-old woman with bipolar disorder, borderline personality disorder, and depression, died from asphyxia by inhalation of liquefied petroleum gas. On 31 March 2024, family unable to contact her requested a p…
18y · Male·compression of the neck in keeping with hanging
An 18-year-old Aboriginal man died by hanging three days after release from prison on home detention bail. He had been displaying acute psychotic symptoms while in prison custody, placed under camera observation due to s…
44y · Male·unascertained - may have been injury from fall, drowning, or predation from mari…
David Ingram, a 44-year-old deckhand, disappeared from the cargo vessel Maersk Mover on 24 September 2021 in the Indian Ocean off Exmouth, WA. He had an undiagnosed paranoid schizophrenia with a history of anxiety, depre…
25y · Male·acute bronchopneumonia and methadone toxicity with high body mass index and obst…
Emmett Brown, a 25-year-old First Nations man, died in custody from acute bronchopneumonia and methadone toxicity, with obesity and obstructive sleep apnoea as contributing factors. He had been denied entry to the Buvida…
2y · Female·sequelae of blunt force head and spinal cord injuries
DB, aged 2 years 9 months, died from blunt force head and spinal cord injuries inflicted by her mother's boyfriend after DCJ closed its case in August 2015. The coroner found DCJ made multiple critical failures: acceptin…
36y · Female·head injury
A 36-year-old woman was killed by a young man with early-onset schizophrenia after a chance encounter. The death resulted from a complex series of missed opportunities in mental healthcare management. Key failures includ…
41y · Female·frontal lobe ischaemic infarcts (strokes) caused by cerebral artery vasospasm co…
A 41-year-old woman died from frontal lobe ischaemic infarcts caused by cerebral vasospasm complicating subarachnoid haemorrhage from a ruptured aneurysm. She presented to multiple healthcare providers over five days wit…
53y · Male·Acute myocardial infarction due to triple vessel atherosclerosis and thrombosis …
A 53-year-old man with chest pain on exertion presented to his GP in March 2022. Initial investigations (blood tests, chest X-ray) were ordered but follow-up was delayed until July 2022. A cardiology referral was made, a…
69y · Male·septic shock with multi-organ failure in a man with neutropenic sepsis on a back…
Colin Nicholson, a 69-year-old man, died from septic shock with multi-organ failure due to acute myeloid leukaemia (AML). Missed opportunities occurred at multiple levels: the PathWest laboratory scientist failed to refe…
62y · Male·Septic arthritis complicating left knee joint prosthesis in the setting of statu…
A 62-year-old man with autism spectrum disorder, cerebral palsy, and epilepsy died from septic arthritis of a prosthetic left knee joint. He presented with fever, knee pain, and delirium in November 2022, three months po…
89y · Male·combination of biochemical consequences of colonic pseudo-obstruction and faecal…
An 89-year-old man with multiple comorbidities including previous colon cancer died from faecal impaction and stercoral colitis. He resided in a residential aged care facility (RACF) where staff failed to recognize that …
50; 37y · Male; male·Mark John Furlan: hypoxic brain injury due to acute neck compression due to hang…
Two men died by hanging while detained under inpatient treatment orders at Ward 2G of Royal Adelaide Hospital. Mark Furlan (50) died in 2018 after developing psychotic depression with suicidal ideation. The coroner found…
53y · Male·Metastatic pancreatic carcinoma
Michael Sanderson, a 53-year-old Gamilaroi man, died from metastatic pancreatic cancer while in custody. Critical clinical lessons emerge: (1) failure to review pathology results within required 14-day timeframe delayed …
47y · Male·Compression of the neck arising from hanging
47-year-old man with antisocial personality disorder, psychosis, and methamphetamine use died by hanging. He presented to emergency departments on 10, 19, and 20 September 2021 with suicidal ideation, auditory hallucinat…
35y · Male·Neck compression due to hanging
Joshua Gonzalez, 35, died by suicide on 5 September 2020 after being discharged from Footscray Hospital. He had been apprehended by police under section 351 of the Mental Health Act after threatening self-harm and asking…
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