2,427 results
42y · Male·multiple injuries sustained in aircraft crash resulting from port side wing tip …
Philip Scholl, an inexperienced microlight pilot with only 20 hours flight training, died in a crash near Mareeba on 20 October 2005. The aircraft T2-2776 was airworthy unfit due to degraded wing fabric, corroded cables,…
14y · Female·blunt force head injury
A 14-year-old Aboriginal girl with newly diagnosed idiopathic thrombocytopenic purpura (ITP) and critically low platelet count (5,000/mm³) absconded from Alice Springs Hospital on 27 January 2006. Hospital staff failed t…
60y · Male·asphyxia sequential to hanging due to depression
Robert Harris, a 60-year-old man with depression, made two suicide attempts within 24 hours. After the first attempt on 27 June 2006, he was discharged from Cairns Base Hospital Emergency Department with a plan to attend…
48y · Female·Unknown
Christine Maria Fenner, aged 48, disappeared from her home on 12 February 1999 and is presumed dead. In the days before her disappearance, she was observed to be in extremely poor health with concerning signs including f…
18y · Male·neck compression due to hanging
Rowan Wheaton, aged 18, died by hanging at supported accommodation in April 2006. He had Aspergers Syndrome diagnosed at age 4, with escalating behavioural and mental health crises from adolescence. Despite multiple emer…
26y · Male·severe closed head injury associated with severe fractures of the cranial vault …
Two remand prisoners died by jumping from mezzanine floors at Adelaide Remand Centre. Andrew Gill (26) died 2 June 2005 after jumping 1 June; Simon Schaer (70) died 15 December 2005. Critical failure: police possessed in…
Female·death by drug toxicity
Melanie Boyd, a teenager, died from drug toxicity at an unsupervised youth party where she consumed illicit drugs, prescription medications, and excessive alcohol. The inquest revealed critical failures in recognising he…
35y · Male·neck compression due to hanging
A 35-year-old man with chronic depression, alcohol dependence and amphetamine abuse was detained at the Queen Elizabeth Hospital Emergency Department on 15 May 2006 after presenting intoxicated with suicidal ideation. He…
26y · Male·Air embolism due to ruptured spleen (surgery) due to motorcycle accident
John Mathers, 26, died from air embolism during emergency surgery following severe motorcycle trauma. A sedan turned across his path; despite heavy braking, he collided and suffered extensive injuries including ruptured …
62y · Female·Haemorrhage caused by abdominoperineal excision of the rectum
A 62-year-old woman died of uncontrollable haemorrhage following an abdominoperineal excision of the rectum (APER) at a remote hospital. The coroner found the operation itself was inappropriate: performed for undiagnosed…
47y · Female·Cardiac arrhythmia due to severe coronary artery atherosclerosis
A 47-year-old woman presented to a level one rural hospital with chest pain. The doctor diagnosed muscular pain (99% certain) and discharged her without troponin testing or admission, despite chest pain being the present…
12y · Male·Suicide by hanging
A 12-year-old Aboriginal boy living in a remote Queensland community died by suicide by hanging following his placement in alternative care by child protection services. The boy had multiple vulnerabilities including fet…
60y · Male·haemopericardium due to rupture of right ventricle complicating removal of cardi…
Richard Allen, a 60-year-old man with a permanent pacemaker for sick sinus syndrome, died from haemopericardium due to rupture of the right ventricle during pacemaker lead extraction on 2 November 2005. The 14mm perforat…
10y · Female·Head injuries due to fall from a bunk bed
Elise Neville, aged 10, fell from a non-compliant bunk bed and sustained a head injury. At her first ED presentation to Caloundra Hospital at 3:25am, Dr D.—a junior house officer 19 hours into a 24-hour shift—failed to p…
64y · Female·acute subdural haemorrhage sustained after a fall on Ward 4A
Margaret Winter, 64, died from acute subdural haemorrhage following a fall on Ward 4A on 13 December 2006. She had been admitted with decompensated liver disease. Her falls risk was misclassified as low when it should ha…
78y · Male·pneumonia with dehydration and exposure to heat as contributing factors
Peter Limbunya, a 78-year-old Aboriginal elder, died from pneumonia complicated by dehydration and exposure after being left unattended at a remote airstrip following hospital discharge. He was not accompanied by a requi…
38y · Male·coronary atherosclerosis
Robert Taylor Daly, a 38-year-old Aboriginal man, died of coronary atherosclerosis with severe coronary artery blockage and pulmonary edema. He collapsed in a drinking area after consuming alcohol while acutely ill with …
Male·Hypoxic brain injury arising from intra-uterine asphyxia (causative factors unas…
William Keays was a neonate born at 37 weeks via emergency caesarean section for fetal distress during labour induction with Syntocinon. He was stillborn with Apgar scores of 0/0/1, requiring 12 minutes of resuscitation …
31y · Female·right cerebellar cerebrovascular accident (cerebellar infarction with obstructiv…
31-year-old woman presented with acute onset headache, dizziness, vomiting, facial numbness and speech difficulties. Initial CT brain showed equivocal left temporal hypodensity. Dr B. diagnosed acute migraine/benign posi…
41y · Male·Head Injury in a Man with Acute Alcohol Intoxication; basal skull fracture with …
Ronald Gregory Kidner, 41, died from a basal skull fracture and severe head trauma on 25 October 2004, four days after falling at a recreation club while acutely intoxicated. He presented to Nickol Bay Hospital with sign…
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