2,427 results
68y · Female·Hypoxic Ischaemic Encephalopathy as a result of Hanging
A 68-year-old woman with longstanding psychotic illness presented to ED with acute relapse, homicidal ideation toward her husband, and vague suicidal threats. Psychiatry assessed suicide risk as low based on her denial o…
49y · Male·Complications of penetrating sharp force injuries through the chest and abdomen …
Graeme Leslie Syme (Beasley), a 49-year-old male on parole with methamphetamine use history, died from penetrating chest and abdominal stab wounds he self-inflicted. Key clinical lessons: his case involved self-harm foll…
29y · Male·Effects of fire
A 29-year-old Afghan asylum seeker died by self-immolation in bushland after deliberately pouring petrol over himself and igniting it. He had been diagnosed with significant mental health issues during immigration detent…
Unknown·Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin M…
This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia fr…
44y · Male·coronary artery disease superimposed upon chronic obstructive pulmonary disease …
John Benedict Munkara died at age 44 following cardiac arrest while in police custody after being found at Vestey's Beach. He had suffered severe, chronic alcohol abuse with multiple protective custody episodes. Critical…
0y · Male·Head injuries (birth trauma) secondary to obstructed labour and fetal macrosomia…
Nixon Martin Tonkin died from head injuries sustained during caesarean delivery for obstructed labour at 38 weeks gestation. The infant's head became deeply impacted in the maternal pelvis after prolonged second-stage la…
0y · Male·Amniotic fluid aspiration (severe); with contribution from thin umbilical cord a…
Archer Langley died at age 1 hour from severe amniotic fluid aspiration following delivery by emergency caesarean section for obstructed labour. His mother's labour was prolonged and difficult, but critical delays occurr…
0y · Male·Traumatic head injury
BJay Adam Johnstone, 45 days old, died from severe traumatic head injury inflicted by his father Simon Johnstone in a household environment. BJay suffered multiple episodes of violence including head trauma, rib fracture…
28y · Male·Brain death due to large right acute subdural haematoma sustained as a result of…
David Browne died from brain death due to a subdural haematoma sustained during a professional boxing match on 11 September 2015. The coroner found the death was preventable. Critical failures occurred: the referee did n…
47y · Male·Pneumonia
Steven Pimblett, 47, with mild intellectual disability, died of pneumonia at home. A home care worker noticed significant health deterioration over two months—inability to walk, laboured breathing, swollen feet—and suspe…
68y · Female·Coronary heart disease
A 68-year-old woman with diabetes, hypertension, hypercholesterolaemia, COPD and chronic renal failure presented with chest pain and dyspnoea. She was admitted with suspected congestive cardiac failure; troponins were no…
73y · Female·Multiple organ failure due to or as a consequence of sepsis due to or as a conse…
73-year-old woman died 12 days after elective colorectal surgery for synchronous caecal and rectal tumours. Post-operatively, she developed persistent low urine output and intermittent hypotension managed with repeated f…
9y · Female·peritonitis due to perforated small bowel due to blunt abdominal trauma
Nine-year-old Leila Baartse-Harkin died from peritonitis due to a perforated small bowel sustained when she fell from a swing. Despite three medical encounters within 36 hours, the perforation was never diagnosed. At a r…
35y · Female·Incised wound to neck
KH, a 35-year-old woman, was killed by her de-facto partner C through severe neck lacerations inflicted with a kitchen knife on 20-21 January 2011. C had an extensive history of violent offences and was subject to a prot…
69y · Female·peritonitis due to dislodged percutaneous endoscopic gastrostomy (PEG) tube
A 69-year-old woman with pyelonephritis developed peritonitis and died after a percutaneous endoscopic gastrostomy (PEG) tube became dislodged. The tube dislodgement was suspected on 11 December 2015 when the patient was…
76y · Male·multiple organ failure due to large volume aspiration of gastric contents during…
Maurice Nancarrow, 76, died from multiple organ failure following aspiration of gastric contents during anaesthetic induction for cystoscopy on 15 August 2015. He had undergone colorectal surgery on 30 July with complica…
46y · Female·combined effects of aspiration pneumonia due to gastroparesis following sleeve g…
A 46-year-old woman died from aspiration pneumonia due to gastroparesis following sleeve gastrectomy, complicated by ischaemic heart disease. Post-operative recovery was beset with persistent vomiting, dehydration, and e…
24y · Male·inhaled solvent toxicity (from petrol sniffing)
Edward James Laurie, a 24-year-old man with chronic petrol sniffing addiction since age 10 and underlying mental health issues including psychosis, died from inhaled solvent toxicity on 11 October 2015. Sixteen Applicati…
37y · Female·open finding - undetermined
Katherine Ackling-Bryen disappeared on 19 February 2016 and is presumed dead. She had a history of schizophreniform psychosis with a 2013 hospitalisation during which she expressed suicidal ideation. Post-discharge, she …
18y · Female·neck compression due to hanging
An 18-year-old female with depression and anxiety was admitted to a psychiatric intensive care unit (PICU) following acute suicidal ideation. Clinically significant issues included: inadequate communication of previous s…
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