136 results
47y · Male·Multiple injuries due to or as a consequence of a motor vehicle accident
Trevor Toms, 47, died in a head-on motor vehicle collision after driving at speed on the wrong side of a rural highway. He had epilepsy managed with sodium valproate but had experienced multiple seizures in the months be…
48y · Female·malnutrition in association with sepsis on a background of end stage multiple sc…
A 48-year-old woman with end-stage multiple sclerosis died from malnutrition and sepsis after her husband, her primary carer, failed to provide adequate nutrition via a PEG tube despite receiving training and instruction…
41y · Male·Subdural haematoma
A 41-year-old Aboriginal man with excessive alcohol use presented four times to a rural hospital over one month with headaches. His symptoms were attributed to cluster migraine, then alcohol withdrawal syndrome, despite …
75y · Female·hypovolaemic shock following uncontrolled blood loss from mini-liposuction stem …
A 75-year-old woman with advanced frontal lobe dementia died from hypovolaemic shock following uncontrolled bleeding after an unproven stem-cell liposuction procedure. Critical failures included: failure to cease anticoa…
53y · Male·Bilateral ACA stroke
A 53-year-old man presented to the emergency department with acute stroke symptoms (left-sided hemiplegia and dysphasia) with onset around 10:30 am. Due to fluctuating symptoms and delays in stroke team referral, he was …
55y · Male·Complications of right middle cerebral artery infarction
Simon Mark Everill, a 55-year-old man with intellectual disability and epilepsy, suffered a right middle cerebral artery infarction on 3 September 2014 after experiencing two falls during a day service activity. His symp…
48y · Female·Acute respiratory failure (cerebral hypoxia) in a woman dependent on non-invasiv…
Michelle Griffin, 48, with motor neurone disease, died from acute respiratory failure while dependent on non-invasive ventilation (NIV) at home. A carer, Julie Manessis, was caring for her when the humidifier tipped over…
48y · Female·Ischaemic brain injury secondary to toxicity to tramadol and temazepam
A 48-year-old woman died from ischaemic brain injury caused by overdose of tramadol and temazepam. She was found unresponsive at home on 10 October 2009 after consuming these medications. Her family and GP Dr Dixit faile…
78y · Male·Cerebral infarction and hypoxic brain damage due to the combined effects of isch…
Paul Henri, 78, died from cerebral infarction and hypoxic brain damage following aspiration pneumonia and opioid-related complications. He was admitted to an aged care home and commenced on MS Contin (morphine) 30mg dail…
51y · Male·Combined effects of atherosclerotic cardiovascular disease and seizure activity …
John Spence, a 51-year-old man with a history of seizures, alcoholism, and severe coronary artery disease, died in a prison health centre following a seizure episode. He had ingested an extraordinarily high level of caff…
31y · Female·raised intracranial pressure due to ventriculoperitoneal shunt dysfunction (disc…
Emilie Le Coz, aged 31, died from raised intracranial pressure secondary to ventriculoperitoneal shunt disconnection. She presented to hospital in March 2010 with progressive headaches, cognitive changes and behaviour de…
46y · Female·Cardiac arrest of unknown origin
Virginia Brown, a 46-year-old Aboriginal woman, died of cardiac arrest of unknown origin on 31 October 2014 while detained under a Mandatory Residential Treatment (MRT) order at CAAAPU (Central Australian Aboriginal Alco…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
A 56-year-old woman presented to Knox Private Hospital with severe headache and eye symptoms on 16 June 2007. An ED physician diagnosed ischaemic stroke based on a subtle CT finding in the absence of focal neurological s…
2y · Female·pneumonia in a child with reported recent flu-like illness (multiple viral detec…
Armarnie-Bree Elliott, a 2-year-old child with Angelman syndrome, died from severe pneumonia with multiple viral infections (adenovirus and enterovirus/rhinovirus) complicated by toxic levels of oxycodone detected at pos…
69y · Female·Asphyxiation consistent with hanging
A 69-year-old woman admitted to Hornsby Hospital with seizures and subacute encephalopathy developed rapidly fluctuating mental state including anxiety, depression, suicidal ideation, and cognitive impairment. While indi…
80y · Male·Drowning
An 80-year-old man with severe depression, suicidal ideation, and probable vascular dementia died by drowning after leaving a psychiatric ward. He was appropriately treated with ECT, medication, and placed on an ITO. How…
35y · Female·homicide by smothering/suffocation, possibly facilitated by chloroform exposure
This tragedy involved the deaths of Preetika Sharma (35), her two children (Divesh, 5; Divya, 3), and her husband Nilesh, who killed his family and then himself. Mr Sharma exposed family members to chloroform before smot…
5y · Male·unascertained
A 5-year-old boy and his sister (3 years old) and mother were killed by their father between 28-29 April 2012 in their Glen Waverley home. The father, who had experienced cognitive impairment and mood changes following a…
3y · Male·Brainstem ischaemia in association with Arnold Chiari malformation
Matthew Whyte, a 3-year-old with Arnold Chiari malformation and hydrocephalus, died from brainstem ischaemia following multiple shunt complications and emergency decompression surgery. The coroner found that after Matthe…
59y · Male·Suicide by hanging while suffering from a mood disorder in the nature of deliriu…
A 59-year-old man died by suicide on 5 January 2009, 47 days after undergoing Deep Brain Stimulation (DBS) surgery for Parkinson's disease. Post-operatively, he experienced significant behavioural changes including agita…
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