2,427 results
11y · Male·unascertained
An 11-year-old child with Cornelia de Lange Syndrome and severe congenital heart disease died alone at home while his mother was intoxicated and unwell. He had complex care needs and was non-verbal. The Department of Com…
50y · Female·Multiple stab wounds to the abdomen and chest
Michelle Michell, a 50-year-old woman, was stabbed to death by her estranged husband Neville in a premeditated domestic violence homicide on 30 June 2021. Critical lessons include: (1) police failed to recognise escalati…
30y · Female·tricuspid valve bacterial endocarditis
Jennifer Collins, a 30-year-old intravenous methylamphetamine user, died from tricuspid valve bacterial endocarditis on 6 September 2018. She presented to Noarlunga Hospital ED on 20 August 2018 with chest tightness, fev…
17y · Male·stroke (left middle cerebral artery infarction) following motorbike collision du…
Kane Mathew Leary, 17, died from a stroke (left middle cerebral artery infarction) following a motorbike collision. The critical clinical lesson involves a missed diagnosis of left internal carotid artery dissection on i…
6y · Unknown·methadone toxicity
A 6-year-old boy died from methadone toxicity after ingesting his parents' takeaway methadone mixed in juice at home. Both parents were on the NSW Opioid Treatment Program (OTP). The prescribing physician increased metha…
29y · Male·cardiac arrhythmia triggered by myocardial ischaemia arising from physical exert…
Brandon Rich, a 29-year-old Aboriginal man, died from cardiac arrhythmia triggered by myocardial ischaemia following a police struggle at his home. He had undiagnosed severe coronary artery disease (75-90% narrowing), mo…
58y · Female·Unascertained
Colleen Mary South, aged 58, was found deceased on 8 August 2022 under a tree in a remote rural paddock in Bunguluke, Victoria, approximately 1.5 kilometres from her abandoned vehicle. She had a significant psychiatric h…
41y · Female·ligature compression of the neck (hanging)
Petya, a 41-year-old Bulgarian-born woman, died by ligature compression of the neck while an involuntary psychiatric patient at Bentley Health Service Ward 6 on 16 December 2020. She had been admitted following acute psy…
83y · Female·meningitis with sepsis with the likely source of infection being a large and dee…
Dorothy Jean Atkins, aged 83, died on 9 July 2017 from meningitis and sepsis secondary to a large stage 4 sacral decubitus ulcer. Autopsy revealed severe malnutrition (24.5kg, BMI 13), poor hygiene with faecal soiling un…
92y · Female·Consequences of an assault
A 92-year-old woman with dementia died from consequences of an assault by another resident with unmanaged psychosis in an aged care facility. The assault occurred after the facility failed to adequately monitor, assess, …
31y · Male·Unable to be determined (uncertain whether drowning or other cause following app…
A 31-year-old man with schizoaffective disorder and substance use was admitted involuntarily to the Kiloh Centre after presenting in acute psychosis with suicidal ideation on 1 April 2017. His psychotic symptoms rapidly …
39y · Female·Sudden cardiac arrhythmia following the administration of Kambo frog toxin
Natasha Lechner, a 39-year-old woman with chronic pain from degenerative disc disease, died from sudden cardiac arrhythmia triggered by Kambo frog toxin administration during a ceremony. She had completed Kambo practitio…
65y · Male·complications, including pneumonia, of traumatic brain injury
A 65-year-old male prisoner died from complications of severe traumatic brain injury sustained when punched by another prisoner at Hakea Prison. He fell backwards, striking his head, and was assessed at the prison medica…
33y · Male·Complications of methylamphetamine use
Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health di…
33y · Male·Irreversible hypoxic brain injury secondary to acute cocaine toxicity
Omar Mohammad, a 33-year-old man with recent mental health concerns and drug use, ingested a small plastic bag containing cocaine whilst being arrested for trespass on 10 August 2020. He died 44 days later from irreversi…
47y · Male·ligature compression of the neck (hanging)
A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which wer…
22y · Female·Complications of cutaneous burns
A 22-year-old woman from Afghanistan died from complications of severe burns (75%+ body surface area) sustained during self-immolation on 5 February 2018. She was experiencing family violence from her husband and in-laws…
31y · Male·Hanging
Timothy Garner, a First Nations man with bipolar disorder and schizophrenia, died by hanging in custody at MRRC on 7 July 2018, five days after being cleared from Risk Intervention Team (RIT) management. The coroner foun…
26y · Male·Not able to be determined - skeletalised remains
Subash Subedi, a 26-year-old international student from Nepal, died in a stormwater drainage system beneath the M2 Motorway between February 2018 and April 2019. He presented to Westmead Hospital ED on 14 February 2018 w…
70y · Male·severe metabolic acidosis due to multi organ failure including liver ischaemia
70-year-old Sean Thomas Montgomery died from severe metabolic acidosis and multi-organ failure following a thoracoscopic repair of a chronic right diaphragmatic hernia. The coroner identified multiple significant failing…
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