2,427 results
22y · Male·Immersion in water (drowning) in a man with combined drug effect
Jaxon Charles Kinnane, 22, drowned in the Swan River on 12 October 2020. He had chronic schizophrenia with persistent delusional beliefs (microchip in ear) and was a polysubstance user, particularly methylamphetamine. He…
58y · Male·Hanging
Zoran Alic, a 58-year-old Serbian-born man detained at Marngoneet Correctional Centre on family violence charges, died by hanging on 29 April 2019. He was referred for psychiatric assessment on 28 March 2019 after report…
83y · Female·Pulmonary thromboembolism due to aortic stenosis (recent transcatheter aortic va…
An 83-year-old woman with severe aortic stenosis, atrial fibrillation, and heart failure died from pulmonary embolism one day after discharge following transcatheter aortic valve replacement (TAVI). Clinical lessons cent…
5y · Female·myocarditis
A five-year-old girl died from fulminant myocarditis caused by influenza A on 5 July 2022 at Canberra Hospital. The diagnosis was delayed over 7 hours from initial presentation. Critical failures included: ED triage Cate…
0y · Male·Trisomy 21 with complex cardiac anomalies complicated by pulmonary hypertension,…
Baby G, born with Trisomy 21 (Down Syndrome) and complex cardiac anomalies, died at Royal Darwin Hospital on 18 March 2023 aged 6 months. The coroner found that non-invasive prenatal testing (NIPT) should have been offer…
1y · Female·Multiple injuries (subdural clot, multiple rib fractures, injuries to liver, blo…
A 20-month-old girl died from fatal injuries inflicted by her mother's partner. She presented to hospital twice in two weeks with suspicious injuries: facial injuries on 7 June attributed to a puppy, and more extensive f…
41y · Male·Septicaemia secondary to chronic peptic ulcer disease
Simon Cartwright, a 41-year-old man with schizophrenia and bipolar disorder, died in custody from septicemia secondary to chronic peptic ulcer disease. He had a documented ulcer history diagnosed in November 2020 and sho…
37y · Male·unascertained
Cyril Levitsky disappeared from Callan Park Hospital in 1970 while under treatment for schizophrenia. He was never found, though an unidentified male body discovered nearby in December 1970 may have been him. Despite ext…
31y · Female·unlawful homicide (manslaughter); specific cause could not be determined due to …
NW, aged 31, was killed by her partner on 9-10 October 2021 in Kununurra, Western Australia. She had a history of domestic violence victimization and had obtained a Family Violence Restraining Order. On the evening of he…
0y · Unknown·unascertained
A 10-day-old neonate born at 36 weeks gestation presented to hospital with signs of sepsis including hypothermia, lethargy, poor feeding, and jaundice. Critical failures in recognition and triage occurred: the infant was…
27y · Male·Cardiac arrest due to cardiac arrhythmia triggered by prone restraint (some of w…
Michael Peachey, a 27-year-old First Nations man, died in custody following a police-initiated restraint during an acute psychotic episode. Over preceding days, his family repeatedly sought mental health intervention. On…
Multiple causes: Child 1 - blunt force trauma to chest and abdomen; Child 2 - he…
This cluster inquest examined four Victorian child deaths (2015-2017) involving parents' partners as perpetrators. Children 1-4 died from blunt force trauma, head injury, fire, and neck laceration respectively. Key syste…
57y · Male·partially suspended hanging
A 57-year-old man with longstanding alcohol use disorder, anxiety, and recent-onset suicidal ideation died by hanging in hospital after a 108-day admission for orthopaedic injuries sustained from intentional jumping. He …
Female·Domestic violence homicides: Miss Yunupiŋu—stab wound to chest; Ngeygo Ragurrk—b…
This landmark coronial finding examines four domestic violence deaths of Aboriginal women in the Northern Territory—Miss Yunupiŋu (2018), Ngeygo Ragurrk (2019), Kumarn Rubuntja (2021), and Kumanjayi Haywood (2021)—all ki…
11y · Male·complications of bowel obstruction in the setting of chronic constipation
RDZ was an 11-year-old Aboriginal boy who died from complications of bowel obstruction secondary to chronic constipation with a fecalith. He had been under paediatric care for years with multiple admissions for bowel was…
2y · Male·Pneumonia
A 2-month-old Aboriginal infant died of pneumonia on 17 July 2019. Key clinical lessons: (1) Fever in infants <3 months requires careful evaluation per RCH guidelines, including investigations and admission for observati…
82y · Male·sepsis due to infected sacral ulcer with osteomyelitis and necrotising fasciitis
An 82-year-old man with multiple comorbidities developed a sacral pressure injury during admission to a private hospital for investigation of leg weakness. Despite being assessed as high-risk for pressure injury, he was …
31y · Male·Undetermined
Ashley Washington, a 31-year-old Kamilaroi man, died after police restraint and sedation during arrest in Toowoomba. He was apprehended following a report of property theft and stabbed a police dog and officer with sciss…
2y · Male·accidental drowning
A 2-year-old boy drowned at a public pool in a remote Australian community during a childcare centre excursion. Critical clinical and organisational failures contributed: no formal risk assessment was documented for the …
49y · Female·stab wound to the neck
Noeline Dalzell, a 49-year-old Aboriginal woman, was fatally stabbed in the neck by her partner James Fairhall on 4 February 2020 after 17 years of escalating family violence. Multiple systems failed to protect her and h…
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