2,427 results
31y · Female·Compression of the neck
Caitlin O'Brien, a 31-year-old nurse, was murdered by her intimate partner Shea Sturt via compression of the neck on 25 June 2019. The coroner identified multiple systemic failures in family violence recognition and risk…
54y · Male·Hypoxic/ischaemic brain damage caused by blood loss and airway obstruction due t…
A 54-year-old male was assaulted in a nightclub with a single punch causing orbital and facial fractures and posterior epistaxis. He presented to the Royal Hobart Hospital ED with active bleeding. Critical deficits in hi…
52y · Male·hanging
A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he be…
58y · Male·acute bronchopneumonia
Giovanni Trotta, aged 58, died in custody from acute bronchopneumonia. He was a vulnerable prisoner with COPD, schizoaffective disorder, and profound deafness. Clinical lessons include: (1) hospital discharge summaries m…
61y · Male·congestive cardiac failure due to cardiomegaly with left ventricular hypertrophy
A 61-year-old man with diabetes, obesity, and high cholesterol presented to his GP with shortness of breath for 4-5 days and tachycardia (HR 120). The GP diagnosed anxiety instead of cardiac failure, failed to ask critic…
20y · Male·hypoxic ischaemic encephalopathy secondary to displacement of tracheostomy and p…
Adam Fitzpatrick, a 20-year-old with complex facial and skull fractures from a motor vehicle collision, underwent emergency tracheostomy placement. On 22 August 2020, 13 days later, his tracheostomy tube became dislodged…
2y · Unknown·Hypoxic-ischaemic encephalopathy following sepsis related to abdominal surgical …
BCT was a 2-year-old Aboriginal child with complex needs from a genetic disorder (CAMTA1 mutation) who died from hypoxic-ischaemic encephalopathy following sepsis related to bowel perforation after a percutaneous endosco…
29y · Male·Effects of fire
Manmeet Sharma, a 29-year-old bus driver, was killed on 28 October 2016 when Anthony O'Donohue, an untreated patient with severe psychotic illness characterised by persecutory delusions, boarded his bus and set him on fi…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
A 74-year-old woman presented to ED with left leg swelling and calf pain. She was triaged as category 4 and seen by a doctor after a 4-hour 24-minute delay due to staff shortages and access block. A D-Dimer test showed e…
71y · Female·complications of metastatic endometrial carcinoma, treated palliatively
Corazon Contreras Keeley, a 71-year-old woman with postmenopausal bleeding, was investigated for possible endometrial cancer. Dr K. performed a hysteroscopy with dilation and curettage (HDC) on 29 November 2019, observin…
62y · Male·cardiac arrest complicating psychotic episode
Michael Adams, aged 62 with chronic treatment-resistant schizophrenia, died from cardiac arrest complicating psychotic episode at a supported residential facility. During escalating psychotic behaviour, paramedics applie…
36y · Female·Stab wound to the right chest
Amanda Jane Harris, 36, was fatally stabbed by her intimate partner Daniel Eckersley on 7 July 2018 in Cranbourne North, Victoria. Eckersley was prescribed high-dose tramadol (700-800mg daily) for chronic pain over 22 mo…
53y · Male·Neck compression in the circumstances of hanging
A 53-year-old man with sudden-onset major depression died by hanging after being discharged from acute mental health crisis services. He presented with depressive symptoms, suicidal ideation with vague plans, and failed …
68y · Female·Pulmonary embolism due to deep venous thrombosis secondary to fractured left dis…
Mary Morrow, aged 68, died from pulmonary embolism and deep vein thrombosis following a fractured left ankle sustained in Queensland on 23 June 2021. She received appropriate VTE prophylaxis initially (enoxaparin) but th…
28y · Female·Multiple injuries sustained in a fall from height
Ruby-Lee Gold, a 28-year-old with schizoaffective disorder and polysubstance abuse, died from multiple injuries sustained falling from an overpass after absconding from Sunshine Hospital's emergency department. She was r…
76y · Male·small bowel obstruction in the setting of terminal metastatic neuro-endocrine tu…
A 76-year-old Aboriginal man died of small bowel obstruction from metastatic neuro-endocrine tumour after spending nearly two years requesting medical help in prison without receiving a doctor's review. Between October 2…
Unknown·Self-inflicted gunshot wound; suicide
Three Australian Federal Police (AFP) appointees died by suicide using AFP-issued firearms: Richard Roberts (57, PSO), Samantha Baglin (44), and Dominic Coleman (52, ASO). All three had untreated mental health conditions…
46y · Male·Methylamphetamine toxicity and coronary atherosclerosis
A 46-year-old man died in police custody following a domestic violence order breach arrest in Rockhampton, Queensland. The death resulted from a combination of methylamphetamine toxicity, significant coronary artery dise…
43y · Male·compression of the neck due to hanging
A 43-year-old male veteran died by hanging in a psychiatric inpatient unit while under a Level 2 Inpatient Treatment Order. He was admitted after a high-lethality suicide attempt involving overdose and carbon monoxide ex…
66y · Male·unascertained (differential diagnosis: chronic alcoholism with alcohol withdrawa…
Colin Norman, a 66-year-old man with significant disability from traumatic brain injury, chronic alcoholism and liver cirrhosis, died at home after failing to receive essential disability support services over a weekend.…
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