2,427 results
29y · Male·Hanging
Craig Mark Allen, aged 29, died by hanging in cell 211 of Yatala Labour Prison on 16 October 2000, six days after admission for assault. Critical failures in prisoner management contributed to this preventable death. The…
77y · Male·bilateral pulmonary emboli complicating deep vein thrombosis (left calf)
A 77-year-old man with dementia died from bilateral pulmonary emboli complicating deep vein thrombosis of the left calf. He was hospitalised for dehydration and diabetes management, then returned to psychiatric care. On …
21y · Male·Cardiorespiratory arrest associated with butane abuse by inhalation
A 21-year-old detained psychiatric patient died from cardiorespiratory arrest following deliberate butane inhalation in a hospital wardrobe. He was admitted to an open mental health ward following acute psychosis, with d…
43y · Female·neck compression due to hanging
A 43-year-old woman with longstanding depression and previous suicidal ideation presented to Emergency Department twice within 14 days and was referred to psychiatric services. She had persistently refused antidepressant…
67y · Male·Aspiration of vomit associated with alcohol intoxication in a man with ischaemic…
Eric Clarence Moody, a 67-year-old man with diabetes, chronic alcoholism, and ischaemic heart disease, died on 6 December 1999 after aspirating vomit while heavily intoxicated with methylated spirits. He presented to Nor…
0y · Male·Hypoxic Ischaemic Encephalopathy (no legal death of person found; coroner declin…
A full-term infant, Matthew Anthony McPhail, was delivered at 9.55 pm on 9 July 2000 at Naracoorte Health Service with no signs of life (Apgar 0). CTG monitoring during labour showed concerning fetal bradycardia episodes…
25y · Female·inhalation of petrol (hydrocarbon inhalation)
This is a complex coroner's inquest into three Aboriginal deaths from petrol inhalation on the Anangu Pitjantjatjara Lands. Kunmanara Hunt, age 25, died on 27 January 2001 after inhaling petrol fumes while lying face-dow…
34y · Female·Dothiepin toxicity in a setting of post-natal depression
Debra Smeeton, 34, died on 12 November 1999 from dothiepin toxicity following intentional overdose at home, eight days after giving birth. She had severe post-natal depression after her first child in 1996, requiring hos…
47y · Female·serotonin syndrome due to combined toxicity of moclobemide and paroxetine
A 47-year-old woman with a long history of prescription drug abuse died from serotonin syndrome caused by combined toxicity of moclobemide (MAOI) and paroxetine (SSRI). She had experienced multiple previous overdoses and…
17y · Male·cranial and facial trauma
A 17-year-old male with acute schizophrenia died from cranial and facial trauma after running off a 15.6-metre cliff during a psychotic episode. Hours before, he had been seen by a trainee psychologist who failed to reco…
17y · Female·mixed drug toxicity
Nicole Davies, 17, died from mixed drug toxicity after rapid methadone dose escalation during early maintenance therapy. She presented with clear signs of intoxication (drowsiness, slurred speech, incoherence) yet receiv…
17y · Female·mixed drug toxicity
Nicole Memory Faye Davies, age 17, died on 4 April 2000 from mixed drug toxicity. She enrolled in methadone maintenance with GP Dr T. on 27 March after moving from Melbourne. Dr T. rapidly escalated her dose from 35mg to…
26y · Male·Ligature compression of the neck (Hanging)
Scott Davidson, a 26-year-old recently sentenced prisoner with paranoid schizophrenia, died by suicide in Casuarina Prison on 5 June 2000. Following sentencing to 9 years imprisonment, he was transferred to Casuarina Pri…
26y · Female·cardiorespiratory arrest due to massive gastric dilatation with gastric rupture
Assunta Petroccia, a 26-year-old woman, died from cardiorespiratory arrest due to massive gastric dilatation with rupture following a bulimic episode. She presented to hospital with severe abdominal pain and was incorrec…
21y · Male·multiple injuries from fall from water tower
A 21-year-old man with acute psychosis was admitted involuntarily to a psychiatric ward after being found climbing a power pole. After 8 days, despite being assessed at moderate suicide risk and displaying poor insight i…
56y · Female·subarachnoid haemorrhage complicating berry aneurysm of the right middle cerebra…
Margaret Joyce Taylor, aged 56, died from subarachnoid haemorrhage due to rupture of a berry aneurysm on the right middle cerebral artery. She presented to three medical practitioners over 6 days with progressive occipit…
Male·Effects of Fire
Five volunteer firefighters (Stuart Davidson, Garry Vredeveldt, Christopher Evans, Jason Thomas, Matthew Armstrong, aged 17–47) from Geelong West died when their tanker was trapped and destroyed by fire during the Decemb…
34y · Male·neck compression due to hanging
A 34-year-old man with longstanding psychiatric illness died by hanging four days after discharge from psychiatric hospital. He had been admitted twice in August-September 1999 with active suicidal ideation and homicidal…
47y · Male·neck compression due to hanging
Wayne Mark Thomson, aged 47, died by hanging on 14 February 2000. He made multiple attempts to seek help for suicidal ideation in the preceding three days, including visiting his GP, calling a crisis assessment service (…
15y · Male·compression of the neck by hanging
A 15-year-old Aboriginal male, Johnno Wurramarrba, from Groote Eylandt died by hanging in Don Dale Juvenile Detention Centre on 10 February 2000, while serving a 28-day sentence for property offences. Key preventable fac…
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