2,427 results
15y · Female·hanging
Harmony, a 15-year-old girl, died by hanging at a motel on 14 January 2020 in circumstances of longstanding neglect, family violence and school disengagement. The coroner found multiple systemic failures: DCJ closed case…
48y · Male·Multiple traumatic injuries
Alan James Green (Wally), aged 48, died on 14 December 2021 from multiple traumatic injuries sustained in a motorcycle crash while being pursued by NSW Police for failing to stop at a traffic stop. The police decision to…
20y · Male·Drowning precipitated by a seizure
Cameron De Vries, a 20-year-old man with severe autism spectrum disorder and global developmental delay, died by drowning precipitated by a seizure in a bathtub at a disability support home. He had experienced a seizure …
75y · Female·multiple organ failure due to severe anaemia secondary to blood loss post electi…
A 75-year-old woman died from multiple organ failure due to severe anaemia after elective hysterectomy surgery. Critical failures occurred: the surgical and anaesthetic teams held conflicting understandings about whether…
78y · Female·Bronchopneumonia
CFT, a 78-year-old woman with chronic schizophrenia, intellectual disability, and dementia, died of bronchopneumonia with hypothermia and coronary atherosclerosis. She lived with her nephew RDS who was her carer. Multipl…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
A 43-year-old woman died from severe diffuse hypoxic brain injury caused by excessive sodium bicarbonate administration during treatment of amitriptyline overdose. The treating ED consultant prescribed sodium bicarbonate…
82y · Male·Ischaemic heart disease due to coronary atherosclerosis with significant contrib…
An 82-year-old man with advanced ischaemic heart disease and emphysema died from myocardial infarction while in custody in the Acute Care Management Unit of a correctional facility. Correctional officers failed to read h…
38y · Male·Compression of the neck (hanging)
Jason Muir, a 38-year-old Aboriginal man, died by suicide 24 days after release from custody. He had complex psychosocial needs including mental health issues, substance use history, and prior suicide attempts. While rei…
46y · Male·Respiratory arrest secondary to acute exacerbation of bronchial asthma caused by…
A 46-year-old man with poorly controlled asthma and known ibuprofen hypersensitivity presented to a rural hospital with chest pain. A remote on-call doctor prescribed aspirin without knowledge of the allergy or availabil…
Female·drowning (all three deceased)
This coronial finding examined three flood-related deaths in Tasmania during June 2016 following exceptional rainfall. Mary Allford drowned when her Latrobe home was inundated; Trevor Foster was swept away at Ouse; Peter…
0y · Female·Complications of ascending uterine infection (Klebsiella pneumoniae) in the sett…
Mia Rose Iskander died at 8 hours of age from ascending uterine infection (Klebsiella pneumoniae) with chorioamnionitis following maternal premature pre-labour rupture of membranes (PPROM) at 32 weeks. Maternal managemen…
35y · Male·Hyponatraemia, with psychogenic polydipsia and schizophrenia/schizoaffective dis…
Daniel Turnbull, aged 35, died in custody from hyponatraemia secondary to psychogenic polydipsia whilst in a 24-hour surveillance cell at Bathurst Correctional Centre. He had a long history of schizophrenia managed with …
27y · Male·Multiple blunt force injuries from jumping off a cliff
A 27-year-old involuntary mental health patient absconded from a hospital transfer vehicle and subsequently died by jumping from a cliff. Critical failures included: absence of clinical assessment before transfer despite…
47y · Female·acute respiratory failure in the context of known underlying chronic obstructive…
Rita Alimankinni (Pukumani), aged 47, died from acute respiratory failure while an involuntary mental health patient in the Joan Ridley Unit. Her death was preventable. She had COPD, obesity, and received multiple high-d…
64y · Male·complications in association with thermal injuries in a man with underlying chro…
Kim Vulich, a 64-year-old man with decompensated liver cirrhosis from chronic alcohol use, developed hepatic encephalopathy and cognitive impairment including possible Korsakoff syndrome. Despite SAT guardianship orders …
15y · Male·Combined heroin and methamphetamine toxicity
T, a 15-year-old boy subject to a Care by Secretary Order, died from combined heroin and methamphetamine toxicity on 24 November 2019. He had experienced multiple placement instability (over 20 placements in two years), …
13y · Male·asphyxia as a result of hanging
MS, a 13-year-old Year 8 student, died by suicide by hanging on 16 February 2020. In the weeks before his death, MS engaged in self-harm by cutting his arms and expressed suicidal ideation to close friends through online…
2y · Male·Hyaline membrane disease and pneumonia in the setting of pneumothorax
A 2-day-old term infant (2670g, small-for-gestational-age) presented with respiratory distress at 11 hours of life. A capillary blood gas at 1:14pm showed mixed respiratory and metabolic acidosis indicating decompensatio…
89y · Male·Cervical spine trauma
Robert Driver, 89, died from cervical spine trauma sustained after being struck by another dementia-affected resident in an aged care facility. He was assessed overnight at the facility and transferred to hospital the fo…
Unknown·COVID-19 infection with various comorbidities as contributing factors
This inquest examined 19 COVID-19 deaths at Newmarch House residential aged care facility in April-May 2020. Deaths occurred during inadequate infection control, severe staffing shortages, and suboptimal clinical managem…
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