2,427 results
Boyd Lyle Scotty Farrer: Ligature compression of the neck (hanging); Esmay Alber…
Five Aboriginal people died in Oombulgurri, a remote East Kimberley community, between March 2005 and April 2006: four by suicide and one in a motor vehicle accident. Boyd Farrer (16), Alicia Rex (15), Paul Mitchell (21)…
24y · Female·Ligature compression injury to the neck (hanging)
Kirsty Anne Slater, a 24-year-old woman with extensive mental illness and substance abuse history, was found hanging from a tree in a park on 19 April 2006, nine days after absconding from Fremantle Hospital's Alma Stree…
29y · Male·aspiration pneumonia complicating acute and chronic Wernicke's encephalopathy an…
Grant Austin, a 29-year-old man with intellectual disability and morbid obesity, died from aspiration pneumonia complicating Wernicke's encephalopathy. He presented with prolonged refusal to eat and drink from December 2…
45y · Male·choking on food
Richard Mann, a 45-year-old man with intellectual disability and psychiatric illness residing in an institutional setting (Strathmont Centre infirmary), died from choking on food. Critical failures in observation and mon…
37y · Female·unlawful killing
Kath Bergamin, a 37-year-old woman, disappeared from her home in Wangaratta, Victoria on 18 August 2002. She had recently left her husband John following years of psychological and physical abuse, obtaining intervention …
0y · Male·hypoxic ischaemic encephalopathy
Riley Krol, a 11-day-old male infant, died from hypoxic ischaemic encephalopathy following emergency caesarean section delivery on 1 March 2005. After artificial rupture of membranes during labour induction, the foetus d…
23y · Male·gunshot wounds to the head
A 23-year-old male was fatally shot in the head by a 17-year-old assailant on 28 February 2004. The coroner identified systemic police failures preceding the death that presented opportunities for intervention. Police fa…
gunshot wounds; multiple deaths during police interventions with mentally ill in…
Between October 2003 and February 2006, Queensland police shot and killed four young men suffering from severe mental illness during crisis situations. In all four cases, the shootings were legally justified as the offic…
Multiple causes across 22 deaths: ligature compression of the neck (17 hangings)…
This coronial inquiry examined 22 deaths of Aboriginal people in the Kimberley region of Western Australia between 2000 and 2007. Seventeen were self-harm deaths, with four additional accidental deaths and one homicide. …
71y · Female·undetermined
71-year-old woman found dead in unusual position at Brighton aged care facility. Her body was positioned with head resting against bed pole, with marks on neck and bruising observed by carers. The death was certified as …
18y · Male·methadone toxicity
Thomas Ryan Keough, aged 18, died from methadone toxicity at Palm Lodge, a supported residential facility for people with mental illness, in August 2003. His body was not discovered for 48 hours after death. The coroner …
16y · Female·Respiratory arrest due to the depressant effect of opiate medication
Vanessa Anderson, 16, suffered a depressed skull fracture from a golf ball strike and was admitted to Royal North Shore Hospital. She died from respiratory arrest due to opioid-induced respiratory depression, which was e…
70y · Male·Acute coronary occlusion due to extensive coronary atherosclerosis
Kenneth Maggable, a 70-year-old man with chronic obstructive pulmonary disease, asthma, and prostate cancer, presented twice to Cairns Base Hospital on 8 August 2005 with respiratory complaints. After discharge at 4:50 A…
28y · Male·hypovolemia secondary to haemorrhage from operative exploration of multiple stab…
A 28-year-old Aboriginal male died from hypovolemic shock following operative exploration of multiple stab wounds to the thigh. The death was preventable. Critical failures included: delayed surgery from Friday to Saturd…
49y · Female·Intra-abdominal haemorrhage, septic and haemorrhagic shock as a result of a lapa…
Deborah Burgen died from intra-abdominal haemorrhage complicated by septic shock following delayed emergency surgery for bowel obstruction. She attended the emergency department six times over eleven days with identical …
14y · Female·Ligature compression of the neck (suicide)
Gabrielle Mia Tedeschi, a 14-year-old girl with longstanding oppositional and self-harm behaviours and subsequent depression, died by suicide on 14 October 2004 following a ligature compression injury sustained on 11 Oct…
Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease
Marjorie Joyce Tanner, an elderly woman with Alzheimer's disease, presented to Maryborough Hospital with a three-day history of abdominal pain, distension, and vomiting. Initially diagnosed with simple constipation and t…
66y · Female·Blood loss due to tearing of the spleen and fractured ribs occasioned by a motor…
Nola Walker, a 66-year-old retired nurse, died from splenic rupture and haemorrhage caused by blunt force trauma from a motor vehicle accident. She was involved in a minor crash, assessed by paramedics who found normal v…
31y · Male·Upper airway obstruction due to pharyngeal abscess caused by dental abscess, whi…
Karl Scholz, 31-year-old male, died from upper airway obstruction due to pharyngeal abscess originating from untreated dental infection. He presented with severe facial cellulitis and abscess following dental procedures …
37y · Male·acute heart failure caused by multiple drug toxicity (methadone and alprazolam)
Richard Mark Kiel, a 37-year-old with chronic opioid addiction, died from acute heart failure caused by lethally high levels of methadone and alprazolam, likely consumed on 9 September 2005. His GP, Dr G., prescribed the…
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