2,427 results
45y · Female·mixed drug toxicity including heroin and methylamphetamine
Barbara Dobson, a 45-year-old woman with a long history of substance abuse, violent relationships, and mental health issues, died of mixed drug toxicity including heroin and methylamphetamine on 24 February 2020. Police …
42y · Male·heroin and methylamphetamine toxicity
Simon Miles, a 42-year-old First Nations man with severe heroin and methylamphetamine dependence, died from accidental drug overdose while on Stage 2.5 of the Compulsory Drug Treatment Program (CDTP). Despite progressing…
37y · Male·Gunshot wound to the head, with alcohol intoxication a significant contributing …
John Fredrick Schulte died by a self-inflicted gunshot wound on Christmas Day 2018 following the breakdown of his marriage. The inquest identified critical failures in police response to multiple domestic violence compla…
43y · Female·Complications of obesity including cardiomegaly
Katrina Jane Cervasio, a 43-year-old woman with intellectual disability, obesity, sleep apnoea, and cerebral palsy, died from complications of obesity including cardiomegaly while living in a disability services group ho…
64y · Male·Complications of metformin toxicity on a background of undiagnosed renal impairm…
Peter Gretton, a 64-year-old man imprisoned at Junee Correctional Centre, died from metformin toxicity complicated by acute renal impairment and severe lactic acidosis. His renal function deteriorated in the three to fou…
81y · Male·Head injury sustained in a fall
Michele Valentino, 81, died from a head injury sustained in a fall on 20 December 2019, with death occurring on 24 December 2019. A CT angiogram at 3:45pm showed worsening intraventricular haemorrhage (IVH) that was not …
27y · Male·Hanging
Marcus Caldwell, a 27-year-old with well-controlled schizophrenia on clozapine, died by suicide in February 2018. He worked at a pet boarding facility that experienced severe staffing shortages during peak season, result…
0y · Male·hypoxic ischaemic encephalopathy due to intrapartum asphyxia
Bodhi Leo Searle, aged 36 hours, died from hypoxic ischaemic encephalopathy due to intrapartum asphyxia. He was born to a woman in low-risk labour managed initially by independent midwife Stephanie Geyer. When labour did…
75y · Female·Renal failure and ketoacidosis in a woman with chronic alcoholism and type 2 dia…
A 75-year-old woman with type 2 diabetes and chronic alcoholism died from renal failure and ketoacidosis at home. She was isolated, dependent on her elderly husband for care, and living in squalor. Over 20 disclosures of…
31y · Male·Hanging
Mr A, a 31-year-old man with a history of family violence, substance misuse, and mental health issues, died by hanging in April 2018. Key clinical lessons include: (1) the importance of regular, systematic mental health …
81y · Female·Subdural haemorrhage from fall with exacerbation by anticoagulant therapy
An 81-year-old woman with atrial fibrillation and Alzheimer's disease fell at home on 21 December 2020, sustaining a subdural haematoma. Nambour Hospital appropriately ceased her anticoagulant (rivaroxaban) and planned c…
27y · Female·carbon monoxide intoxication due to voluntary and intentional inhalation of exha…
A 27-year-old woman with a lengthy history of depression, anxiety, and previous suicide attempts died by carbon monoxide poisoning. She was referred to mental health crisis services on 4 July 2020 with documented suicida…
34y · Male·ischaemic heart disease secondary to coronary atherosclerosis as an antecedent c…
Reuben Button, a 34-year-old Aboriginal man, died in custody from ischaemic heart disease secondary to coronary atherosclerosis. During his 5-year imprisonment, his weight increased from 86kg to 162kg despite attempts at…
51y · Male·complications of opiate toxicity; cardiac and respiratory arrest following drug …
Ziad Hamawy, a 51-year-old man with chronic schizophrenia and polysubstance use disorder, died from opiate toxicity after cardiac arrest following his discharge from Concord Hospital's mental health unit on 18 March 2019…
74y · Male·Pulmonary thromboembolism secondary to deep vein thrombosis in the setting of re…
A 74-year-old man died from pulmonary thromboembolism secondary to deep vein thrombosis following a cervical spinal fracture. He presented to rural ED with mental health concerns, was restrained by security guards after …
12y · Female·Hypoxic ischaemic encephalopathy complicating an aortic root abscess (operated) …
A 12-year-old Aboriginal girl with a bicuspid aortic valve and autism spectrum disorder presented with a week of fever and non-specific symptoms (cough, vomiting, abdominal pain, chest pain) to a rural hospital. Despite …
73y · Male·unknown
A 73-year-old man with dementia and frontal lobe impairments disappeared from a nursing home on 5 January 2018; his remains were discovered a year later in a nearby river. Critical clinical and organisational failures oc…
43y · Male·Hanging
GS, a 43-year-old man with complex mental health history (depression, anxiety, borderline personality disorder, substance use), died by hanging in Goulburn Correctional Centre after 183 days in custody. The critical fail…
0y · Female·Fetal demise due to placental abruption and sepsis secondary to chorioamnionitis…
Ashlee Reindl died hours after birth in 2019 following a prolonged induction of labour complicated by fetal distress and chorioamnionitis. A catastrophic placental abruption occurred shortly before emergency caesarean se…
26y · Male·hanging, intentionally self-inflicted
A 26-year-old Aboriginal man died by suicide in custody following discharge from a Risk Intervention Team (RIT) management plan on 19 October 2021. He had self-harmed on 17 October, reporting voices telling him to cut hi…
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