2,427 results
43y · Female·External neck compression due to self-inflicted hanging
A 43-year-old NSW Police officer died by suicide on duty while suffering from work-related Major Depressive Disorder and PTSD. She had a suicide attempt in November 2012 that was not formally investigated as a new incide…
29y · Male·Unascertained causes on a background of agitated delirium state
A 29-year-old man with a 12-year history of mental illness died in police custody during transport to a police station. He had stopped taking his antipsychotic medication (Risperidone 4mg daily) following GP advice to re…
32y · Female·massive postpartum intracerebral haemorrhage of spontaneous hypertensive origin
A 32-year-old woman with Factor V Leiden mutation died from a massive postpartum intracerebral haemorrhage of hypertensive origin five hours after delivering twins. She had been diagnosed with pregnancy-induced hypertens…
37y · Male·methyl amphetamine intoxication while being restrained in a confined space; posi…
Adam Southwick, a 37-year-old man severely intoxicated with methamphetamine, was placed in a cramped police charge dock while handcuffed and unable to walk. He died from methamphetamine intoxication complicated by positi…
37y · Male·Multiple injuries (motor vehicle impact – pedestrian)
Justin Connell, a 37-year-old man with schizophrenia, died from multiple injuries sustained in a pedestrian–motor vehicle collision on 13 February 2013. He had been diagnosed with schizophrenia in October 2012 and prescr…
77y · Male·Complications of reaction to an iron infusion in a man with ischaemic heart dise…
A 77-year-old man with iron deficiency anaemia and underlying ischaemic heart disease died from anaphylaxis following iron polymaltose infusion. Critical clinical lessons: (1) IV iron should only be administered after or…
37, 9, 5y · Female, male, male·Effects of fire
Three deaths (mother and two young sons) resulting from a fire deliberately set by the mother. A 37-year-old educated woman from India living in Australia experienced escalating isolation, marital conflict, and lack of e…
48y · Female·Head injury
Frances May Cooper, a 48-year-old woman with chronic paranoid schizophrenia, died from head injuries after being struck by a train on 30 October 2011 while on unescorted leave from the mental health unit at Kalgoorlie Re…
38y · Female·multiple stab injuries to the chest and abdomen
A 38-year-old woman was fatally stabbed by her former partner, Bradley Carolus, in May 2010. Three days before the homicide, Carolus had been apprehended by police under mental health legislation following a volatile epi…
18y · Female·Severe cardiogenic shock caused by myocarditis as a consequence of an unknown vi…
Ivy Dwyer, 18, died from viral myocarditis causing cardiogenic shock. She presented over weeks with progressive non-specific symptoms (nausea, vomiting, fatigue, cough) consistent with viral illness. A locum GP diagnosed…
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…
23y · Male·Hanging whilst suffering acute mental illness, most likely a first episode delus…
A 23-year-old man in custody died by hanging in May 2011 while experiencing untreated first-episode psychosis with paranoid delusions. He had expressed suicidal ideation on 20 April and was assessed by a Risk Interventio…
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…
4y · Female·Haemorrhage due to aorto-oesophageal fistula caused by ingestion of a button bat…
A 4-year-old girl died from aorto-oesophageal fistula and haemorrhage caused by a lithium button battery lodged in her oesophagus for at least 3 days. Critical diagnostic failures occurred: the initial GP failed to consi…
23y · Male·injuries sustained when struck by train
Jarrod Christie, 23, a voluntary then involuntary psychiatric inpatient at Maroondah Hospital, absconded from the high-dependency unit on 22 December 2012 and died by suicide. Clinical lessons include: (1) GPs should ful…
4y · Female·Injuries sustained in fall from height
Darcey Iris Freeman, aged 4, was fatally injured when her father threw her from the West Gate Bridge on 29 January 2009 during a parenting dispute. Her mother had disclosed to GPs fears that the father could harm the chi…
22y · Female·Effects of burns
Sargun Ragi, a 22-year-old woman recently arrived from India on a spousal visa, was killed by her husband Avjit Singh in October 2012 after obtaining an intervention order and leaving their relationship. The coroner foun…
83y · Female·undetermined (likely hypothermia based on clinical findings)
An 83-year-old woman with advanced Alzheimer's and vascular dementia died alone at home between April-August 2013. The coroner found the direct cause undetermined (likely hypothermia) but highlighted critical preventable…
38y · Male·Combined effects of methylamphetamine toxicity, violent struggle, and positional…
Kevin Norris, 38, died in police custody after methamphetamine intoxication, violent police restraint at McDonald's, and positional asphyxia at Bowral Police Station. He had schizophrenia and was on a Community Treatment…
45y · Female·Multi-drug toxicity
Christine Drinnan, aged 45, died from multi-drug toxicity involving lethal morphine levels combined with pethidine, quetiapine, benzodiazepines and alcohol. Over 12 years, her GP Dr H. prescribed dangerous quantities of …
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